North Shore Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 33162 Based on review of medical records, policies and procedures, on-call physician schedules, interviews, and video surveillance, it was determined the facility failed to provide, within the capabilities of the staff and facilities available at the hospital, adequate medical examination and treatment for 1 of 20 sampled patients reviewed, Patient #1, who presented to the ED (Emergency Department) at Hospital A on 09/20/25 at 9:57 PM with chief complaint of severe vaginal bleeding. Hospital A discharged Patient #1 home on 09/21/25 at 3:10 AM, with discharge instructions to see a gynecologist emergently the next day. At the time of discharge, Patient #1’s blood pressure had decreased from 144/115 upon arrival to 95/57 at 2:00 AM despite intravenous fluids and an ultrasound at 12:04 AM that showed no free fluids but a CT scan at 1:59 AM (less than 2 hours later) showed ‘fluid filled endometrial cavity.’ Patient #1 was not offered further medical screening or transfer to another hospital offering gynecology services since they did not have gynecology services on call. Patient #1 did not receive medical treatment and interventions of her conditions necessary to stabilize the identified emergency medical conditions, including care to assure there would not be material deterioration after discharge, such as excessive blood loss. Cross Refer to additional findings at A2406.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 33162 Based on observation, review of census data for the hospital’s locality, and interview, the provider failed to post the required signage in the languages understood by the population served by the Hospital. The findings included: During tours of the ED (Emergency Department) on 11/13/25 beginning at 3:59 PM and 11/18/25 beginning at 3:55 PM, signage by the ED walk-in entrance and ED ambulance entrance informing persons of their rights to examination and treatment for emergency medical conditions and women in labor was observed posted in English and Spanish, but not in Haitian-Creole. Further observation of the ED revealed signage for Patient’s Bill of Rights and Notice of Privacy Rights & Practices were posted in English, Spanish and Creole in the lobby near the walk-in entrance. Review of the 2023 5-year census data from Census Reporter reveals in Lauderdale Lakes (the city in which Florida Medical Center is located) 59.3% of the population speaks only English; 32.2% of the population speak French, Haitian or Cajun with 17.4% speaking French, Haitian or Cajun but English less than “very well;” and 5.4% of the population speak Spanish with 1.9% of the population speaking Spanish and English less than “very well.” During a telephone interview on 11/19/25 at 12:00 PM, the Chief Executive Officer stated the predominant languages of the area are first English, then Spanish, then Creole; and stated his belief that only English and Spanish signage is required.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 33162 Based on hospital policy, record review, observation, hospital video, and interview, the provider failed to ensure an adequate medical screening exam to determine whether an emergency medical condition existed before discharging 1 of 20 sampled patients (Patient #1). The findings included: Review of the Hospital A’s Policy and Procedure titled Emergency Medical Treatment and Active Labor Act (EMTALA), Policy Number RI 23, last revised 10/04/22, documents under Policy, “Every patient, regardless of ability to pay, who (i) presents to the Hospital’s Dedicated Emergency Department or presents on Hospital Property and (ii) requests an examination or treatment of a potential Emergency Medical Condition (“EMC”) shall receive an appropriate Medical Screening Examination (“MSE”) to determine whether the patient is experiencing an EMC. If it is determined that the patient is experiencing an EMC, the Hospital shall either stabilize the EMC within the capability of the Hospital or transfer the patient to another medical facility in accordance with the provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA) and this Policy.” Observation on 11/13/25 at 3:59 PM of Hospital Emergency Services signage in the Emergency Department lobby near the walk-in entrance reveals it documents, “The following services are offered at FLORIDA MEDICAL CENTER” and lists the service name “Gynecology” with a check mark in the column for “Services Available 24 hours a day, 7 days a week,” and “Any patient requesting emergency care will be screened, evaluated and stabilized based on EMTALA regulations.” Review of the Hospital’s license also reveals its Dedicated Emergency Department Services includes Gynecology. Review of the record revealed Patient #1 walked into the emergency room on 09/20/25 at 9:57 PM. Patient #1’s Emergency Room Sign-In Form documents her “Chief Complaint, Symptoms” as “vaginal bleeding & clots - severe.” Patient #1’s ED (Emergency Department) Triage Assessment, created 09/20/25 at 9:58 PM, documents she came from home with complaint of heavy bleeding after intercourse at 5 PM that day, her pulse was high at 95 (reference range 60-90 beats per minute) per pulse ox machine, her BP (Blood Pressure) was high at 144/115 (reference range 90/60-140/90 mmHg) per automatic cuff, and she was assigned an ESI (Emergency Severity Index: a five level triage system in which level 1 is the most urgent) Level of 2 (indicating high-urgency, but not immediately life-threatening). Patient #1’s ED Document, dictated and signed by ED Physician #1, documents Patient #1 was seen by the provider (physician) on 09/20/25 at 10:02 PM and reported vaginal bleeding that started after intercourse six hours prior and that she had not had a menstrual cycle for several years; and on Physical Exam she was alert and oriented x 3 (to person, place and time) with soft, nontender abdomen and GYN (gynecological exam findings) were described as “Normal external genitalia, Other (There is no obvious sign of injury nurse present during examination there is some blood oozing but no active bleeding).” Patient #1’s ED Interventions / Assessments / Treatments include a Vaginal Bleeding Assessment, created 09/20/25 at 10:17 PM, that documents heavy bright red constant vaginal bleeding since 5 PM with 6 sanitary pad changes, associated symptoms “Dizziness,” and that Patient #1 stated she has a copper IUD (Intrauterine Device) that was supposed to be removed four years ago. On 09/20/25 at 10:42 PM, Patient #1’s Hemoglobin was 12.4 (within normal range) and hematocrit 36.9 (low). At 11:27 PM Patient #1’s blood pressure was 105/57. Patient #1’s ED nurse’s notes document on 09/20/25 at 11:36 PM, Patient #1 was given Dilaudid for “nausea/vomiting,” although this was not found in her medication orders or administration record, and the ED record documents under medications that Patient #1 received ondansetron (a medication used to prevent nausea and vomiting) on 09/21/25 at 11:37 PM. The report from Patient #1’s pelvic ultrasound performed 09/21/25 at 12:04 AM documents an indistinct endometrial stripe complex (nonspecific finding), pelvis otherwise normal, and no free fluid. Patient #1’s CT (Computed Tomography) of the abdomen and pelvis with contrast, performed 09/21/25 at 1:59 AM, documents under Impression, in part, “Fluid filled endometrial cavity.” An ED Interventions / Assessments / Treatments entry 09/21/25 at 12:05 AM for Vaginal Bleeding documents Patient #1’s last menstrual period was four years ago and a “medium” amount of bright red constant bleeding, duration 7 hours, and “replaced bed pad d/t (due to) bleeding.” Patient #1’s vital signs at 12:05 AM included a pulse of 76 and blood pressure of 125/62. Patient #1’s ED record documented on 09/21/25 she received metoclopramide (a medicine used to treat heartburn, nausea and vomiting) 10 mg (milligrams) intravenously at 1:09 AM and 1 liter of intravenous normal saline at 1:10 AM. Patient #1’s ED Interventions / Assessments / Treatments entry for 2:00 AM for Vaginal Bleeding documents a medium amount of bright red bleeding, one sanitary pad change, and “pt (patient) passing clots.” Patient #1’s vital signs at 2:00 AM included a blood pressure that was low at 95/57 and pulse of 78. Despite the drop in blood pressure and reports of nausea, vomiting and dizziness in the context of continued bleeding and passing clots, 4 years post menses, and “fluid-filled endometrial cavity” on CT scan just 2 hours after a pelvic ultrasound showed no free fluid, Patient #1 was discharged home to self-care on 09/21/25 at 3:17 AM without evidence of a recheck since 2:00 AM of her blood pressure, bleeding status, or recheck of her hemoglobin and hematocrit. Patient #1’s discharge paperwork in the record included referrals to an OB/GYN (obstetrician / gynecologist) and a local clinic that accepts uninsured patients without any date or timeline for how soon to be seen, although the physician’s own note had indicated she needed to be seen “as soon as possible emergently” by a GYN. Review of Patient #1’s Fire Rescue record reveals emergency services were called on 09/21/25 at 8:44 AM, went to the home where Patient #1 was found sitting on toilet and reported vaginal bleeding since the night before and that she had been discharged from Hospital A that morning after being told it was normal menstrual bleeding, although she hadn’t had a period in 4 years, that bleeding persisted after that discharge and she became lightheaded and was going through 2 pads every 20 minutes, her blood pressure was low at 86/56 mmHg (millimeters mercury), heart rate 59 (beats per minute), and respiratory rate 26 (breaths per minute). Patient #1 was given intravenous fluids and transferred to Hospital B at 9:12 AM. Review of Patient #1’s medical record from Hospital B reveals her hemoglobin and hematocrit levels were critically low at 6.7 and 20.6 respectively and she received blood transfusions. During a telephone interview on 11/12/25 at 1:20 PM, the ED Medical Director stated a fluid filled endometrium could be normal if a patient is menstruating; that an ultrasound is more sensitive than a CT scan for fluid, so the ultrasound should have picked up fluid if there was any; and that her case would have been something to look into more if she was experiencing nausea, vomiting, or dizziness. Upon being informed that Patient #1 had reported nausea, vomiting and dizziness while in the ED, the ED Medical Director then replied he did not see the patient and cannot really give a true opinion on that. During an interview on 11/12/25 at 2:28 PM, ED Physician A confirmed he had seen Patient #1 in the ED on 09/20/25 and 09/21/25 and had a chance to review the record, reported ultrasounds and CT scans would both show fluid, and that Patient #1’s fluid-filled endometrium “absolutely could be blood. She was menstruating.” When reminded that Patient #1 reported no menstruation for four years, he stated postmenopausal bleeding can still happen but when it does you think of a mass, cancer, or ectopic pregnancy; reported on exam there was some blood but it was oozing and “not pouring out” and he saw no IUD strings; denied reassessing the patient for bleeding before her discharge but stated he always asks how patients are doing and if she was bleeding so much she should have said that to him; that although he does not remember the case specifically, he would have kept her if she had said she was bleeding more or that she didn’t think she should leave, so she must not have said that and that there was no report to him that bleeding was increasing or continuing. ED Physician A sated that the hospital does not have a gynecologist on call although one is on staff to see inpatients; and clarified that when he wrote she needed to be seen by GYN emergently in his note, he meant that she needed to be seen the next day and not wait a week, and denied offering a transfer to another facility where she could be seen by gynecology. During interview on 11/17/25 at 2:28 PM, the ED Director stated they have old signage up in the ED lobby since before they lost half of their services and that on call specialty coverage is voluntary unless specifically contracted. Review of the ED video footage for 09/21/25 at 3:14 AM (within 5 minutes of Patient #1’s discharge time) shows a person leaving the Emergency Department in a gown, appearing to be holding something in place under her gown as she walks with one hand on her lower abdomen and another on her backside as carrying a clear bag that appears to be clothing. Further review of the record does not reveal the patient was asked why she could not wear her own clothes but walked out in a hospital gown holding something between her legs. The MSE was inappropriate in that it was not sufficient to determine whether an EMC was present. Specifically, the potential EMC of developing anemia and hemorrhagic shock secondary to vaginal bleeding (from a variety of possible causes) was not adequately ruled out.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 45329 Based on the review of records, interview and policies and procedures review, the facility failed to honor 1 (Patient #1) of 5 patients’ rights by not maintaining a current, accurate, and complete medical record as required. Findings include: Review of Patient #1’s clinical record conducted on 07/24/2024 revealed: Hospital Course: After cesarean section delivery of a baby girl on 09/01/2022, Patient #1 was transferred to the intensive care unit for continued close observation due to severe thrombocytopenia. On 09/06/2022, Patient #1 underwent a bone marrow biopsy performed by the hematologist. After midnight, Patient #1 was in critical condition and expired (possible Immune thrombocytopenia - a blood disorder that causes low platelets and bleeding). Interview conducted on 07/24/2024 at 3:30 PM with the Chief Nursing Officer (CNO) revealed the facility changed electronic medical record systems on October 25, 2022, and they are unable to provide the following documents for Patient #1: 1. Nursing Assessments 2. Medication Administration Records 3. Respiratory Assessments/Notes 4. Stroke Team Assessments/Notes The CNO stated that the facility ceased providing obstetric and neonatal intensive care services as of February 14, 2024, and the Medical/Nursing staff are no longer employed at the facility. Review of the facility’s policy entitled Record of Care Policy Number: ROC 52; Last Revised 09/29/2022 included but wasn’t limited to: Policy: The facility supports the right of an individual to access their accurate and complete health information in a timely manner. In all cases the facility promotes the guarantee of an individual’s right to access their health information under applicable law and the facility policies and procedures. Review of the facility’s policy entitled Policy Document Retention Policy Department: Compliance Policy Number: COM 32; Last Revised 09/26/2023 included but wasn’t limited to: Policy: The facility retains business and clinical documents for a period of time no less than required by law. Each department Director or Practice Operations/ Administrative Director is responsible for the proper retention, storage and disposal of documents that it generates, maintains and/or receives in the course of doing business. A review of the form entitled Document Retention Schedule, last reviewed on 09/26/2023 documented medical records in Florida hospitals should be retained for adults seven (7) years after the last entry. The facility failed to provide a true and accurate medical record containing information from patient observations, interviews, and treatment provided by medical staff.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 45329 Based on observation, interview, record review, and review of the By-Laws, Articles VIII and IX, the facility’s Governing Body failed in its oversite responsibilities to promote patient safety and performance improvement and provide for organizational management and planning of the Hospital as stated in its Purpose. (1) The Governing Body failed to ensure the hospital Chief Executive Officer (CEO) fulfilled his overall responsibility in the overall organization and management of the Hospital and its services, departments and subdivisions, delegation of duties and establishment of formal means of accountability of subordinates when the recurrence of mold was noted on the second-floor area that was known to be wound care and outpatient surgery. (2) The Governing Body through the Hospital CEO, failed to support activities and mechanisms for evaluating, monitoring, identifying potential problems, and tracking performance to ensure that previous improvements were sustained to maintain the integrity of the closed off area of the second-floor to prevent the reoccurrence of mold in stairwells, wallpaper, walls and ceilings in the area that was known as wound care and outpatient surgery. This failure has the potential to affect all visitors, staff, and inpatients receiving care on the 2nd floor of the hospital. Findings include: Interview with the Director of Clinical Quality Improvement on 05/23/2024 at 11:00 AM revealed there is no hospital-wide performance improvement plan. The Director of Clinical Quality Improvement stated each department does their own data collection. The surveyor requested and was provided with the 2024 Performance Improvement Plan, and the Performance Improvement Committee (Quality Council) Clinical Operations Dashboard dated May 23, 2024, which tracks quality indicators across clinical areas directly involved with delivering patient care. The Director of Clinical Quality Improvement acknowledged the Quality Improvement Committee is not currently actively involved in receiving, analyzing, and recommending strategies to address any significant findings or to reduce the risk of compromising patient safety on the second-floor area that was known to be wound care and outpatient surgery. A tour on the second floor conducted on 05/23/2024 at 4:00 PM in the area that was known to be wound healing care and outpatient surgery revealed exposed walls ceilings and flooring in the process of being removed. The entire area is with visible bio growth (Identified during Life Safety survey on 05/13/2024 and 05/20/2024). The entire area has been closed off and isolated. Do Not Enter signs posted. Observed a digital device with numeric readings on the wall in the small room leading to the main area. Per the Plant Operations Director the device is a negative pressure airflow monitor. Daily readings and documentation of the presence of negative air flow within the construction area are not tracked. Interview with the Chief Executive Officer (CEO) on 05/23/2024 at 5:00 PM, revealed there are separate air handlers and separate structures on the 2nd floor. The CEO stated there is no connection between Tower 1 (first floor) and Tower 2 (second floor), and there is no possibility for air or water contamination. The CEO stated the area has been isolated with negative pressure airflow (floor plans were provided and photos of the mold impacted walls in the second-floor area that was known to be wound care). Interview with the Infection Control Officer on 05/24/2024 10:44 AM revealed an infection control risk assessment (ICRA) was not initiated but will be executed when work is being done. The Infection Control Officer stated the negative air pressure keeps air in the area from circulating to the general population. The Infection Control Officer stated that he/ she was not aware if other areas on the 2nd floor were tested, and they will know what exactly needs to be done after getting an estimate. The Infection Control Officer stated per plant operations, no mold was identified outside of the area. The Infection Control Officer stated there will be a written action plan once they know what will be done. The Infection Control Officer acknowledged the infection control department is not currently actively involved in the demolition, construction, and renovation phases of the second-floor area that was known to be wound care and outpatient surgery. Interview with the Chief Nursing Officer on 05/24/2024 at 10:56 AM revealed the area is sealed off with negative pressure. The Chief Nursing Officer stated that the facility has not received any reports from the Life Safety survey regarding their findings, and Plant Operations is looking for quotes. Infection control will work with Plant Operations once an assessment is done. We will all get together and create a plan. The plan will be submitted to the medical executive committee (MEC) and the medical operations committee (MOC) in Hospital B because we share a license with them. We will probably do a failure mode effects analysis (FMEA) with the entire group and adjust actions based on what’s decided. At 11:30 AM, the Chief Nursing Officer stated asbestos has not been found and Life Safety representative stated that more than likely asbestos may be found when the tiles come up and the work begins. The surveyor requested documentation of the Facility Assessment and QAPI Plan, asbestos abatement and testing of the contaminants in the area were not provided on 05/24/2024 prior to survey exit.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 45329 Based on observation, interview, record review and review the 2024 Performance Improvement Plan, the Quality Assessment Performance Improvement Committee failed to have a planned, systematic, hospital wide approach to implement effective measures to monitor, maintain, and track performance to ensure that previous improvements were sustained to prevent the reoccurrence of mold in stairwells, wallpaper, walls and ceilings on the second-floor area that was known as wound care and outpatient surgery. This failure has the potential to affect all visitors, staff, and inpatients receiving care on the second floor of the hospital. Findings include: Review of the facility’s 2024 Performance Improvement Plan on 05/23/2024 revealed the Performance Improvement (PI) Committee has been delegated oversight of Performance Improvement by the President of each campus to assure that the principles of performance improvement are utilized throughout the organization. The PI Committee has representation from the medical staff and organization leaders and all hospital departments as needed. Councils perform the following functions: 1. Establishes the performance improvement methodology and prioritizes performance activities. 2. Charters performance improvement teams to accomplish process/system and outcome improvements as needed. 3. Provides performance improvement teams with guidance and support. 4. Reviews and approves hospital wide PI activities. 5. Receive, analyze, and recommend action regarding any significant findings from the hospital risk management process and compliance program. 6. Maintain a current written performance/quality improvement plan. 7. Provides information and ongoing communication to the Governing Board, Campus Operations Committee, Medical Executive Committee, Clinical Care Committee and Organization Leaders. Interview with the Director of Clinical Quality Improvement on 05/23/2024 at 11 AM revealed there is no hospital-wide performance improvement plan. The Director of Clinical Quality Improvement stated each department does their own data collection. The surveyor requested and was provided with the 2024 Performance Improvement Plan, and the Performance Improvement Committee (Quality Council) Clinical Operations Dashboard dated May 23, 2024, which tracks quality indicators across clinical areas directly involved with delivering patient care. The Director of Clinical Quality Improvement acknowledged the Quality Improvement Committee is not currently actively involved in receiving, analyzing, and recommending strategies to address any significant findings or to reduce the risk of compromising patient safety on the second-floor area that was known to be wound care and outpatient surgery. A tour on the second floor conducted on 05/23/2024 at 4:00 PM in the area that was known to be wound healing care and outpatient surgery revealed exposed walls ceilings and flooring in the process of being removed. The entire area is with visible bio growth (Identified during Life Safety survey on 05/13/2024 and 05/20/2024). The entire area has been closed off and isolated. Do Not Enter signs posted. Observed a digital device with numeric readings on the wall in the small room leading to the main area. Per the Plant Operations Director the device is a negative pressure airflow monitor. Daily readings and documentation of the presence of negative air flow within the construction area are not tracked. Interview with the Infection Control Officer on 05/24/2024 10:44 AM revealed an infection control risk assessment (ICRA) was not initiated but will be executed when work is being done. The Infection Control Officer stated the negative air pressure keeps air in the area from circulating to the general population. The Infection Control Officer stated that he/ she was not aware if other areas on the 2nd floor were tested, and they will know what exactly needs to be done after getting an estimate. The Infection Control Officer stated per plant operations, no mold was identified outside of the area. The Infection Control Officer stated there will be a written action plan once they know what will be done. The Infection Control Officer acknowledged the infection control department is not currently actively involved in the demolition, construction, and renovation phases of the second-floor area that was known to be wound care and outpatient surgery. Interview with the Chief Nursing Officer on 05/24/2024 at 10:56 AM revealed the area is sealed off with negative pressure. The Chief Nursing Officer stated that the facility has not received any reports from the Life Safety survey regarding their findings, and Plant Operations is looking for quotes. Infection control will work with Plant Operations once an assessment is done. We will all get together and create a plan. The plan will be submitted to the medical executive committee (MEC) and the medical operations committee (MOC) in Hospital B because we share a license with them. We will probably do a failure mode effects analysis (FMEA) with the entire group and adjust actions based on what’s decided. At 11:30 AM, the Chief Nursing Officer stated asbestos has not been found and Life Safety representative stated that more than likely asbestos may be found when the tiles come up and the work begins. The surveyor requested the Facility Assessment for Quality Assessment Performance Improvement (QAPI) projects during an interview with the CEO on 05/24/2024 at 2:30 PM. The CEO stated we do not have a Plant Operations Director at this location. The CEO stated we are in the process of hiring one, the requested information was not provided. Alternatively, the surveyor was provided with various miscellaneous documents related to the 2nd floor: 1. Letter from ( ... ... ...) indicating and estimate for mold and asbestos remediation by May 29, 2024. 2. Letter dated 05/24/2024 from Engineering Director (sister facility) regarding 2nd Floor Empty Unit Action. 3. Email dated 05/24/2024 from Plant Operation Director (sister facility) on Isolation Area. 4. Email dated 05/24/2024 from Director of Clinical Quality Improvement. Subject: Isolated Area. 5. Letter from the Chief Nursing Officer dated 05/24/2024 regarding the analysis of the ICU’s infection rates. The surveyor requested documentation of the Facility Assessment and QAPI Plan, asbestos abatement and testing of the contaminants in the area were not provided on 05/24/2024 prior to survey exit.”

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 32827 Based on observations and interviews the facility failed to maintain essential life safety systems, building integrity, and environmental care of a portion of the building. All areas, systems and buildings in healthcare facilities have to be maintained according to the requirements of NFPA and all of its referenced publications as well as the Florida Administrative Code. Any area or life safety system not maintained can pose harm and danger to all occupants. Findings include: During the Life Safety Survey tour of the facility between 10:00 am and 1:00 pm on 05/20/2024 with the Interim Plant Operations Director, it was revealed on the second floor area known as wound healing care and outpatient surgery that (1) the entire area has been closed off; (2) the roof was leaking; and (3) there was water damage (4) All of the life safety systems and building components not being maintained, and they are the following: 1-Fire Sprinkler system 2-Fire Alarm 3-Fire Doors and Smoke Doors 4-Fire and Smoke Door Hardware 5-Fire Stopping 6-Stairwells 7-Ceiling Tiles 8-Interior smoke and fire walls and finish 9-Medical Gas 10-Electrical circuitry, electric breaker panels and electrical systems 11-Emergency lights and Exit lights 12-Roof 13- Evidence of bio growth in stairwells, wallpaper, walls and ceilings A complete review, testing and maintenance of all of the above listed systems in the area noted is due immediately at this time. NFPA 101 (2012 Edition) sec 4.5.8 sec 4.6.1.2 sec 4.6.12 sec 4.6.12.1 During the Life Safety Survey tour of the facility between 10:00 am and 1:00 pm on 05/20/2024 with the Interim Plant Operations Director, it was revealed that the roof on the second floor on the south side of the building is the original roof from 1959 and has reached the end of its life span. A complete review and written assessment is required and due at this time for the portion of the second floor roof noted from an Engineer, Architect or Master Roofer. . NFPA 101 (2012 Edition) sec 4.5.8 sec 4.6.1.2 sec 4.6.12 sec 4.6.12.1 During the staff interview between 10:00 am and 1:00 pm on 05/20/2024, the Interim Plant Operations Director acknowledged these findings. These findings were also discussed and acknowledged by the Chief Executive Officer during the exit conference.”

“Elevators CFR(s): NFPA 101 Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter’s Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter’s Service Requirements of ASME/ANSI A17.3. (Includes firefighter’s service Phase I key recall and smoke detector automatic recall, firefighter’s service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3 This Standard is not met as evidenced by: 32827 Based on observations and staff interview, the facility failed to maintain the elevators in accordance with the National Fire Protection Association (NFPA) 101. Findings include: During the Life Safety Survey tour of the facility between 11:00 am and 3:00 pm on 05/20/2024 with the Interim Plant Operations Director, it was revealed that: (1) all elevators have expired certificates and inspections; (2) there were 3 out of 7 elevators operational; and (3) there were no repairs completed to inspection reports listed failures and deficiencies. NFPA 101 (2012 Edition) sec 19.5.3 sec 9.4, 9.4.6 sec 9.4.6.1 During the staff interview between 10:00 am and 1:00 pm on 05/20/2024, the Interim Plant Operations Director acknowledged these findings. These findings were also discussed and acknowledged by the Chief Executive Officer during the exit conference.”

“Features of Fire Protection - Other CFR(s): NFPA 101 Features of Fire Protection - Other List in the REMARKS section any NFPA 99 Chapter 15 Features of Fire Protection requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 15 (NFPA 99) This Standard is not met as evidenced by: 32827 Based on observations and interview, the facility failed to protect and store flammable liquids as required by the National Fire Protection Association (NFPA) 99. Findings include: Observation and interview with the interim facilities director on May 20, 2024 between the hours of 10:00 AM to 1:00 PM at the main driveway in front of the main entrance revealed the facility set up a temporary portable diesel water pump for the down lift station for sewage with four 55 gallon drums of diesel fuel that was not protected. The four 55-gallon drums of diesel fuel were directly on the side of the main driveway unprotected with the potential of a vehicle to hit the drums endanger all occupants, patients and staff using the main entrance to enter or exit the facility. The facilities interim facilities director acknowledged the findings. Photographic evidence provided. NFPA 99 (2012 Edition) 15.3, 15.3.1(1) NFPA 30 (2012 Edition) 22.15 NFPA 30 (2012) Edition Sec 22.15”