Sheridan Memorial Hosptial

“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: 47752 Based on interview, record review, and policy review, the facility failed to comply with the requirements in 489.24. The facility failed to provide an MSE (Medical Screening Exam) by a QMP (qualified medical provider) within the capability of the hospital’s ED (emergency department), including ancillary services routinely available to the ED (Emergency Department), to determine whether or not an emergency medical condition existed for 1 (#10) of 21 sampled patients; failed to provide stabilizing treatment within the hospital’s capability prior to the transfer for 1 (#10) of 21 sampled patients; and failed to consult a physician prior to the transfer of an unstable patient for 1 (#10) of 21 sampled patients. Findings include: 1. Patient #10 presented via ambulance on 11/14/25 with altered mental status, possible sexual assault, and potential drugging. Patient #10 did not receive a medical screening exam by a qualified medical professional to determine whether or not an emergency medical condition existed. [A-2406] 2. Patient #10’s altered mental status was not addressed or stabilized prior to transfer to another facility. [A-2407] 3. Patient #10 was transferred to another hospital by an advanced practice provider without prior consultation with a physician. [A-2409] Review of a facility policy titled EMTALA and Anti-Dumping Provisions, dated 12/12/2023, showed: “... I. Medical Screening Examination: A. Provide a medical screening examinations to every individual including women in labor, their unborn child(ren) ... when they present for care to dedicated emergency departments, ... B. If the patient has a emergency medical condition ... the patient must be: 1. Appropriately assessed and provided stabilizing treatment within the hospital’s capabilities ... 2. If unable to stabilize the emergency medical condition, arrange for an appropriate transfer to another hospital with specialized services ... ... III. Patient Transfer (Discharge to other Healthcare Facility) for an emergency medical condition which has not been stabilized, the patient may be appropriately transferred when: ... 4. If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person has signed a certification ... after a physician, in consultation with the person, has made the determination described in such a clause, and subsequently countersigns the certification.” [sic]”

“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: 47752 Based on observation and interview, the facility failed to have EMTALA (Emergency Medical Treatment and Labor Act) signs posted in locations where individuals who presented to the facility for an examination or treatment would readily see and understand their patient rights. This failure had the potential to affect all individuals seeking care at the facility. Findings include: During an observation and interview on 1/13/26 at 12:25 p.m., the door marked A1 in the administrative area had no EMTALA signage posted in the area. Staff member F stated at times, patients would enter into the administrative doors looking for the emergency department. During an observation on 1/13/26 at 12:34 p.m., the EMTALA sign was noted on the bulletin board at the emergency department entrance. The sign was on white paper and hanging amongst other papers. When walking through the emergency department double doors, the sign was not easily identifiable as an EMTALA sign. The room labeled “emergency room” off to the right of the emergency department entrance did not have EMTALA signage present. During an observation on 1/13/26 at 12:36 p.m., down a small hallway from the emergency department entrance was a small room labeled “waiting room.” No EMTALA signs were posted. During an observation on 1/13/26 at 12:40 pm., room 11, used as an emergency treatment room and located across from the nurse’s station, had an EMTALA sign. It was located down the hallway, on white paper and was placed on a bulletin board. The placement of this sign was not easily identifiable to patients being transported down the hall or being treated in emergency room 11. During an observation and interview on 1/13/26 at 12:45 p.m., a sliding door located on the northern side of the building allowed patients and visitors entrance into the hospital. No EMTALA sign was observed to be present. Staff member G identified the door as the main entrance for the hospital and long-term care area. Staff member G stated patients do present to the reception desk by the main entrance looking to be evaluated in the emergency department. During an interview on 1/13/26 at 1:35 p.m., staff member B stated there was not a specific policy for EMTALA signs.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 47752 Based on interview, record review, and policy review, the facility failed to ensure that an appropriate Medical Screening Exam (MSE) was performed by a qualified medical provider to determine whether an Emergency Medical Condition (EMC) existed for 1 (#10) of 21 sampled patients who presented to the Emergency Department for care. This deficient practice had the potential to place the patient at risk of harm by delaying recognition of an Emergency Medical Condition. Findings include: Record review of patient #10’s ambulance record, showed the ambulance crew was notified by dispatch on 11/14/25 at 00:26 (12:26 a.m.) of a possible sexual assault and drugging. A GCS (Glasgow Coma Scale) was completed and patient #10 scored a 14 (minor impairment affecting cognition). Hospital A was notified “that the patient would have to divert to that location for stabilization and sedation.” Ambulance crew noted just before arrival to Hospital A, patient #10 “lost consciousness, with a GCS of 3” (a major impairment affecting cogition). She maintained spontaneous respirations but had to have her head repositioned and oxygen was applied at 6 lpm (liters per minute) via NC (nasal cannula). She was unresponsive to painful stimuli for several minutes and became increasingly responsive upon arrival at Hospital A. Report was verbalized to staff member L and the ambulance crew remained on standby. Hospital A staff sedated patient #10 for transfer. During an interview on 1/14/26 at 12:15 p.m., staff member I stated she was on the ambulance crew the night patient #10 required assistance. Staff member I stated hospital staff were provided report about patient #10’s possible assault and were instructed to bypass Hospital A and go straight to Hospital B, as there was no SANE (Sexual Assault Nurse Examiner) on site. Staff member I stated she was at the scene for a prolonged amount of time and during that time patient #10 had become more anxious, confused, and showed a change in her mental status. Staff member I stated Hospital A was contacted again and notified the ambulance would be bringing patient #10 in for an evaluation prior to continuing to Hospital B because of the change in mental status. Staff member I stated on the way to Hospital A, patient #10 lost consciousness but was able to maintain her airway with head repositioning and supplemental oxygen. Staff member I stated staff member L met the ambulance crew outside in the ambulance bay and told them the patient was supposed to go to Hospital B not come to Hospital A. During an interview on 1/20/26 at 9:14 a.m., staff member K stated she was the provider on call the night patient #10 arrived at the Emergency Room. Staff member K stated she did not provide a medical screening exam to determine if an emergency medical condition existed. Staff member K stated, “The patient had been waxing and waning from what I recall. She arrived and was lethargic but would answer direct questions and would become anxious and agitated at times. I admit I dropped the ball on this. I did not do any kind of work up. I focused more on the sexual assault than I did on the altered mental status.” During an interview on 1/20/26 at 10:00 a.m., staff member L stated she was on shift the night patient #10 was brought to the Emergency Room. Staff member L stated earlier in the night she had heard the page for the ambulance. Staff member L stated she had talked with the ambulance crew a couple of times that night because they would call with updates. Staff member L stated staff member K advised the ambulance crew to take patient #10 directly to Hospital B because Hospital A did not have a SANE nurse and was instructed not to stop unless an “emergent” situation arose. Staff member L stated the ambulance called back and stated they were stopping for the patient to be assessed and obtain some medication for transport. She had met the ambulance outside in the ambulance bay. Staff member L stated she reminded the ambulance crew, they were supposed to bypass Hospital A. Staff member L stated there was no workup (diagnostic process), labs, or a blood alcohol content completed on patient #10. During an interview on 1/20/26 at 1:00 p.m., staff member B stated the expectation in the Emergency Department was for the provider to perform a medical screening exam to determine if a medical emergency condition was present. Review of patient #10’s ED (Emergency Department) Triage, dated 11/14/25 at 2:30 a.m., showed a chief complaint of possible sexual assault with possible involuntary ingestion of altering drugs. Patient #10’s respiratory rate was 16 br/min (breaths per minute), and her oxygen saturation was 98% on 4 L/min (Liters per minute) via Nasal cannula. A C-SSRS (Columbia Suicide Severity Rating Scale) screen was not performed due to “Altered mental status.” “Level of Consciousness: Lethargic. Orientation: Not orientated to place or time. Neurological exam GCS 14.” No laboratory tests or imaging results were documented patient #10’s medical record. Review of staff member K’s Emergency Room noted showed, patient #10 was “sedated but arousable. No acute distress ... Seems confused at times.””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, the facility failed to provide stabilizing treatment within its capabilities to a patient who presented to the emergency department with an emergency medical condition (altered mental status) prior to transfer, for 1 (#10) of 21 sampled patients. Findings include: Record review of patient #10’s ambulance record, showed the ambulance crew was notified by dispatch on 11/14/25 at 00:26 (12:26 a.m.) of a possible sexual assault and drugging. A GCS (Glasgow Coma Scale) was completed and patient #10 scored a 14 (minor impairment affecting cognition). Hospital A was notified “that the patient would have to divert to that location for stabilization and sedation.” Ambulance crew noted just before arrival to Hospital A, patient #10 “lost consciousness, with a GCS of 3 (a major impairment affecting cognition). She maintained spontaneous respirations but had to have her head repositioned and oxygen was applied at 6 lpm (liters per minute) via NC (nasal cannula). She was unresponsive to painful stimuli for several minutes and became increasingly responsive upon arrival at Hospital A. Report was verbalized to staff member L and the ambulance crew remained on standby. Hospital A staff sedated patient #10 for transfer. During an interview on 1/14/26 at 12:15 p.m., staff member I stated she was part of the ambulance crew responding to patient #10, and that while enroute to Hospital A, patient #10 lost consciousness and required head repositioning and supplemental oxygen to maintain her airway (ability to effectively breathe). Review of patient #10’s ED (Emergency Department) Triage, dated 11/14/25 at 2:30 a.m., showed a chief complaint of possible sexual assault with possible involuntary ingestion of altering drugs. Vital signs were: Respiratory rate 16 br/min (breaths per minute), Oxygen saturation 98% on 4 L/min (Liters per minute) via Nasal cannula. A C-SSRS (Columbia Suicide Severity Rating Scale) screen was not performed due to “Altered mental status.” “Level of Consciousness: Lethargic. Orientation: Not orientated to place or time.” Review of staff member K’s Emergency Room noted showed, patient #10 was “sedated but arousable. No acute distress ... Seems confused at times.” Review of the provider’s orders showed patient #10 received Ativan (sedative drug that can cause breathing to become too slow or shallow) at 2:40 a.m. and 3:13 a.m. During an interview on 1/20/26 at 9:14 a.m., staff member K stated she was the provider on call the night patient #10 arrived at the Emergency Department. Staff member K stated patient #10 arrived lethargic, responded to direct questions, and intermittently became anxious and agitated. Staff member K stated, “...I did not address her mental status. I focused more on the sexual assault than I did the altered mental status.” Staff member K stated she had ordered Ativan for anxiety and believed the patient received two doses while in the Emergency Department prior to the transfer to Hospital B. Staff member K stated it was not standard practice to administer Ativan in a patient who had alcohol in their system and potentially other substances. Staff member K stated some of the side effects of Ativan were drowsiness, dizziness, and respiratory depression. During an interview on 1/20/26 at 1:00 p.m., staff member B stated it was not standard practice to administer a medication like Ativan to a patient with alcohol or possibly other drugs in their system. Staff member B stated if patient #10 had been combative in the Emergency Room then he could see Ativan being administered. Staff member B stated he did not think patient #10 was being combative. Review of a facility policy titled, “EMTALA and Anti-Dumping Provisions,” with an effective date of 2/4/25, showed: “... Stabilized-emergency medical condition -no material deterioration of the patient’s condition is likely to result from the transfer or is likely to occur during transfer ... b. EMTALA requires physicians and other qualified practitioners to provide care within nationally accepted standards of practice. If the hospital has the capabilities to stabilize the emergency medical condition, it is required to do so ... B. If a patient has an emergency medical condition as described in this policy, the patient must be: 1. appropriately assessed and provided stabilizing treatment within the hospital’s capabilities ...” [sic] A review of Ativan’s side effects and adverse reactions show: “ ... Combining Ativan and alcohol is dangerous, as both are central nervous system depressants that, when combined significantly increase the risk for severe respiratory depression, coma, or death. The combination can cause extreme sedation, severe dizziness, reduced coordination, and dangerous impairment.” Davis Drug Guide-drugguide.com National Library of Medicine-ncbi.hlm.nih.gov”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, the facility failed to ensure that a physician was consulted prior to the transfer of an unstable patient for 1 (#10) of 21 sampled patients. This deficient practice placed an unstable patient at risk for harm by transferring the patient without a physician consultation. Findings include: Review of patient #10’s electronic medical record, dated 11/14/25, showed patient #10 arrived at the emergency department via ambulance at 2:19 a.m. The mid-level provider was notified at 2:32 a.m. and arrived at the bedside at 2:42 a.m. Patient #10 was discharged from Hospital A and transferred to Hospital B at 3:00 a.m. Review of patient #10’s transfer form dated, 11/14/25, showed: “Consulting Dr. [Staff member T] by [Staff member K] Qualified Medical Personnel Date 11/14/25 Time 0200(2:00 a.m.). Consulting Dr. Signature [Staff member T] date 11/14/25 Time 0250(2:50 a.m.).” [sic] The Documentation indicated that the physician consultation occurred at 2:00 a.m., which was prior to patient #10’s arrival in the Emergency Department. During an interview on 1/20/26 at 9:14 a.m., staff member K stated she was the provider on call the night patient #10 arrived at the Emergency Department. Staff member K stated, “I did not consult a physician prior to transferring her out. I should have.” Staff member K stated she did not call and consult with staff member T on 11/14/25. Staff member K stated the only physician contacted was the accepting physician at Hospital B. Review of a facility policy titled, “EMTALA and Anti-Dumping Previsions,” dated 12/12/2023, showed: “... 4. If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person has signed a certification ... after a physician, in consultation with the person, has made the determination described in such a clause, and subsequently countersigns the certification.””

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), a life safety code (LSC) survey was performed on 2/7/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 LSC, 2012 Edition, and those mandatory Codes referenced by that edition. The facility was surveyed specifically using Chapter 19 Existing Health Care Occupancies. The building construction type was found to be Type V (111) and Type II (111) and contains two main floor smoke compartments and one basement smoke compartment. No new construction has occurred since the last survey on 9/29/15. There is a two hour separation between the long term care and CAH on the main level of this building. The CAH is licensed for 19 beds and at the time of the survey 2 patients was the census. These requirements were not met as evidenced by the following deficiencies:”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to ensure doors with automatic self-closing devices were maintained in accordance with NFPA 101-2012, Section 19.2.2.2.7. This deficiency affects 1 out of 1 smoke compartment. Findings include: During an observation on 2/7/24 at 1:06 p.m., the PT Rehab pool door was inspected. The door was fitted with a self-closure and was held open by a rubber wedge.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 40068 Based on observation, interview, and record review the facility failed to: a) failed to ensure the gauges on the sprinkler standpipe were replaced or recalibrated every 5 years in accordance with NFPA 25, 2011 edition, section 6.3.4.1 b) failed to ensure sprinkler piping was fee from external loads in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2 c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3). This deficiency affects all smoke compartments at the facility. Findings include: 1. Review of the facility’s records on 2/7/24 showed the facility’s pressure gauges on the sprinkler standpipe had not been recalibrated since 2018. During an interview on 2/7/24 at 12:58 p.m., staff member C stated the gauges should have been replaced in December of last year (2023). 2. During an observation on 2/7/24 at 12:47 p.m., the server room was inspected. There were cords hanging off the sprinkler piping, as well as a towel wrapped around the sprinkler piping. 3. During an observation on 2/7/24 at 12:55 p.m., the laundry water supply room was inspected. There was a ceiling tile missing. This could impede the sprinkler’s distribution and performance if activated. 4. During an observation on 2/7/24 at 1:10 p.m., the hospital soiled linen room was inspected. There was a ceiling tile missing. This could impede the sprinkler’s distribution and performance if activated.”