The Centers for Medicare and Medicaid Services (CMS) found Glen Oaks to be out of compliance with the conditions of Medicare program participation, as well as federal health care facility standards. CMS found that the facility’s deficiencies with its Quality Assessment Performance Improvement program warranted a “condition-level” violation, meaning the facility could face termination from the Medicare program if the violations were not corrected. Specifically, CMS found that the facility’s governing board “failed to monitor the effectiveness, safety of services, quality of care, and the implementation of measurable processes and goals in the Quality Assessment/Performance Improvement Plan.” CMS also found that the facility did not have a nurse staffing plan to adjust the number of staff based on patient characteristics and administrative activities, instead using only a staffing grid “that indicated how many nursing staff and mental health technicians were needed on each unit based upon numbers.” CMS also found that “2 housekeepers cared for all the housekeeping needs of the 50 bed psychiatric facility.” In its tour, CMS found that areas of the hospital were dirty, with standing water in the kitchen vegetable cooler, stains and unknown substances in seclusion rooms, and dirt and debris in the gymnasium. CMS also cited Glen Oaks for failing to ensure (and document) that 12 of its 14 staff members were adequately trained, and demonstrated competency in, restraint and seclusion techniques. One staff member told CMS surveyors that he taught restraint and seclusion techniques from “personal experience” because there were no formal training materials. Additionally, CMS found that the facility allowed nurses to administer respiratory services to patients, despite lack of formal training, because the facility did not have an organized respiratory services department for eight months. The facility also violated the standards for emergency services by failing to have a designated treatment room for medical emergencies, or policies and procedures governing patient/visitor medical emergencies. A staff member stated that if a patient/visitor fell or experienced a medical emergency, they would be assessed wherever they fell or 911 would be called.