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Based on observation and interview, the psychiatric hospital failed to ensure the patient's right to receive care in a safe setting. This deficient practice was evidenced by the failure to maintain a patient care environment free of ligature risk in 20 patient bathrooms (Rooms a - t).
Findings:

Observations of the psychiatric hospital on 08/26/2025 at 1:30 PM with S1VP revealed the bathrooms of Rooms a - t had toilet seats that were not completely secured to the toilet bowl. This would create a ligature point, which would allow for the potential of self-injurious behaviors by a patient.

In an interview on 08/26/2025 at 2:00 PM, S2VP confirmed the ligature points in the above patient bathrooms.

Based on observation, record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. This deficient practice was evidenced by the failure of the hospital to identify multiple environmental and housekeeping issues throughout the hospital.
Findings:

On 08/26/2025 at 1:30 PM, during tour of the psychiatric hospital with S1VP, multiple environmental and housekeeping issues were identified. These included 20 patient bathrooms (Rooms a - t) that had toilet seats that were not completely secured to the toilet bowl, creating a ligature point that a patient could utilize and 12 patient rooms with no working water faucet at the sink (Rooms a, e, g, h, m, n, o-s, u, v). Observations also revealed maintenance and housekeeping issues such as AC unit leaks, cleanliness in patient rooms and bathrooms, foul odors, and one patient's door hanging off the hinges.

Interview with S1VP during these above observations revealed that he was unaware of these issues. S1VP further stated that staff were supposed to conduct environmental rounds at least twice daily and submit any issues in writing to the administrative team be addressed. When asked if any of these issues had been brought to the administrative team to be addressed, S1VP stated no. When asked if the staff were actually performing rounds twice daily in order to recognize opportunities for improvement, S1VP stated "obviously not".

Based on record review and interview, the hospital failed to ensure that the registered nurse supervised and evaluated the nursing care for each patient as evidenced by failing to perform routine and accurate skin assessments for 3 of 3 patients diagnosed with scabies (Patient #1, 2, 3).
Findings:

Patient #1
Review of a physician progress note dated 07/30/2025 revealed "scabies infestation". The patient has moderate infestation to trunk and hands and itches. The physician ordered the first dose of Permethrin cream to treat the scabies.

Review of a physician progress note dated 08/25/2025 revealed "itching all over". Scabbed areas on abdomen.

Review of the daily nursing assessments revealed the following:
07/30/2025 - no skin assessment documented
07/31/2025 - day shift assessment revealed skin "warm, dry and intact". There was no skin assessment for the night shift documented.
08/01/2025 - no skin assessment documented
08/02/2025 - no skin assessment documented

The patient was in an acute care hospital from 08/09/2025 and returned to the psychiatric hospital on 08/19/2025.

Review of the re-admission nursing assessment dated 08/19/2025 revealed no documented evidence of a skin assessment.

Review of nursing assessments from 08/19/2025 through 08/24/2025 revealed no documented skin assessments.
The nursing assessment dated 08/25/2025 (day shift) revealed "red rash itching".
There were no further skin assessments in the medical record.

On 08/27/2025 at 12:30 PM, interview with S2QA revealed that nurses should perform skin assessments twice daily, once per shift. S2QA confirmed that Patient #1 did not receive twice daily skin assessments on the above dates and the assessments that were performed were inaccurate or incomplete.

Patient #2
Review of a physician progress note dated 07/31/2025 revealed bites to right upper arm, skin excoriated, scabies. The physician ordered the first dose of Permethrin cream.

Review of a physician progress note dated 08/14/2025 revealed patient has crusted scabies bites to left shoulder and bilateral legs, also complains of itching.

Review of a physician progress note dated 08/15/2025 revealed patient has numerous bite marks to left shoulder, left arm, abdomen and back. Skin is excoriated.

Review of the daily nursing assessments revealed the following:
07/30/2025 - day shift nurse documented skin "warm, dry, intact". There was no skin assessment for the night shift.
07/31/2025 - no skin assessment documented
08/01/2025 - no skin assessment documented
08/02/2025 - no skin assessment documented for day shift. The night shift documented "rashes on body and irritation"
08/03/2025 - no skin assessment documented for day shift. The night shift documented "rashes".
08/04/2025 - no skin assessment documented

Further review of the twice daily skin assessments revealed on 08/14/2025 (day shift), the nurse documented "reddened areas" and on 08/15/2025 (night shift), the nurse documented "skin rashes". There were no further detailed assessments of these areas.

On 08/27/2025 at 1:15 PM, interview with S2QA confirmed that Patient #2 did not receive twice daily skin assessments on the above dates. S1QA further confirmed when skin assessments were documented, they were not accurate or complete.

Patient #3
Review of a physician progress note dated 07/30/2025 revealed patient has a history of itching. Moderate scabies infestation to hands, buttocks, abdomen and back. Areas of hands between fingers are crusted and patient complains of itching. The physician ordered the first dose of Permethrin cream.

Review of a physician note dated 08/07/2025 revealed orders to give the second dose of Permethrin cream for continued scabies issues.

Review of the daily nursing assessments revealed skin assessments were not conducted twice daily (per shift) on the following dates: 07/30/2025 - 08/03/2025.
Review of the skin assessment performed on 08/04/2025 (day shift) revealed skin was "warm, dry and intact".

On 08/27/2025 at 1:45PM, interview with S2QA confirmed that Patient #3 did not receive the required twice daily skin assessments on the above dates.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in such a manner that the safety and well-being of the patients are assured. This was evidenced by 1) Failing to ensure that the water faucets in 12 patient rooms were working properly (Rooms a, e, g, h, m, n, o-s, u, v) and 2) Failing to ensure that adequate housekeeping/maintenance was provided throughout the hospital.
Findings:

1. Failing to ensure that the water faucets in 12 patient rooms were working properly

On 08/26/2025 at 1:30 PM, tour of the hospital with S1VP revealed patient Rooms a, e, g, h, m, n, o-s, u and v had no working water faucets in their rooms. When the faucet was turned on, no water came out of the faucet.

During this time, interviews were made with random patients who resided in the rooms with no working water faucet.
The patient in Room e stated "It has been like that for a while."
The patient in Room f stated that his water faucet has not worked "for a while".
The patient in Room g stated his water faucet in his room has not worked since he was admitted in March 2025.
The patient in Room h stated his water faucet has not worked for the past month. The patient stated that he had reported this issue.
The patient in Room o stated he has not had a working water faucet in his room for three weeks.
The patient in Room p stated he has not had a working water faucet in his room "for a long time". When asked how he washes his hands, he stated "I don't".

Interview with S1VP on 08/26/2025 at 2:00 PM revealed that he was unaware that the water faucets in the above patient rooms were not functioning.

2. Failing to ensure that adequate housekeeping/maintenance was provided throughout the hospital

On 08/26/2025 at 1:30 PM, tour of the hospital with S1VP revealed the following:
- The shower room on Unit B had mold/mildew on the upper walls and ceiling.
- Room c had towels at the bottom of the AC unit with visible water stains on the towels. The patient in this room stated that the unit has been leaking water.
- The door on Room f was hanging off the frame. The patient in this room stated that the door had been hanging loose from the frame for a while.
- The light switch in Room h did not work. When the patient was asked how he could see at night, he stated that he has to turn on his bathroom light to be able to see in his bedroom. The patient stated he had reported this a long time ago.
- There was a "water sock" around the bottom of the AC unit in Room m. The patient in this room stated the unit had been leaking for about two weeks.
- The shower walls in Room q had large amounts of rust that had dripped on all sides. There was grime and mildew in the floor of the shower.
- Room t had a horrible urine odor.
- The ante-room bathroom of the seclusion room had large amounts of an old dried brown substance dripping down all sides of the commode.
- Room w had dried red substance on the front of the sink. The commode had large amounts of an old dried brown substance dripping down all sides of it. There was dirt and grime on the floor of the bathroom. Bugs were flying in the bathroom.
- Room x had dirt, grime and debris on the floors in the bathroom. Bugs were flying around the commode.
- Room y had a horrible odor in the room and the surveyor was unable to enter the room due to this odor.

On 08/26/2025 at 3:15 PM, interview with S1VP confirmed the above housekeeping and maintenance issues. S1VP confirmed he was not aware of these issues and that they should have been picked up on the daily environmental rounds the staff is supposed to be performing.