Hospital Metropolitano Dr Pila

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 51637 Based on the review of personnel credential files (CF) and State Law License regulations requirements, it was determined that the facility failed to updated personnel credential files related to professional staff comply with the Cardiopulmonary Resuscitation (CPR), Federal Narcotics License, Hepatitis Vaccine or titers, Influenza Vaccine, COVID 19 Vaccine, background check requirements and Health certificate. (M.S.C.F. #2, #3, #4, #5, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17 and #18) Findings include: The Puerto Rico Health Department regulation 6044 states that health facility will be responsible for ensuring that all its staff maintain current credentials in accordance with the laws applicable to their profession. 1. During the credential files review of Medical Staff (M.S.C.F.) conducted from 07/07/2026 to 07/08/2026 from 8:30AM to 11:30AM, the following was found: a. One out of eighteen credential files failed to show updated evidence of in person Cardiopulmonary Resuscitation (CPR) accredited by the American Heart Association (M.S.C.F #10) b. Thirteen out of eighteen credential files had no evidence of a Hepatitis B vaccine administration or positive titers. (M.S.C.F. #2, #3, #4, #5, #7, #8, #9, #10, #11, #12, #14, #16, #17 and #18) c. Eight out of eighteen credential files had no evidence of an Influenza vaccine administration or a signed rejection. (M.S.C.F. #3, #4, #5, #8, #9, #10, #12 and #15) d. Two out of eighteen credential files had no evidence of a COVID 19 vaccine administration or a signed rejection. (M.S.C.F. #4 and #15) e. Three out of eighteen credential files had an expired health certificate (M.S.C.F. #7, #10 and #16) f. Two out of eighteen credential files had no evidence of a criminal record certificate. (M.S.C.F. #11 a 20423 Based on the review of fifteen nursing credential files (C.F’s), it was determined that the facility failed to ensure that seven nursing personnel are licensed in accordance with state and local laws related to Nursing degree, for 7 out 15 C.Fs (N. C.F. # 1, #2, #3, #5, #7. #9 and #10) Findings include: 1. Review of credential file of the Director of nursing of the facility on 07/09/206 at 9:50 AM with human resources (employee #7) evidence that the person that Acting position since on March 19, 2018. 2. Human resource (employee #7) was asked on 07/09/2026 at 10:00 AM if there is a requirement by the facility that the Director of nursing of the facility had a master’s degree in nursing with concentration in nursing administration services, She stated that it is highly recommended to comply with Puerto Rico (PR) State Law # 254 of December 31, 2015, who regulates the nursing practice in PR. No evidence was found on the Acting director of nursing credential file that she had a master’s in nursing with concentration in nursing administration services. They only evidence that this employee had a bachelor’s degree in nursing. 3. Facility Acting director of nursing (employee #19), was asked on 09/09/2026 at 10:30 AM if she had a master’s degree in nursing with concentration in nursing administration services. She stated that she has a master’s degree in nursing with concentration in nursing administration services since 2018 but she had not made arrangements to acquire the nursing specialized license and credentials, since actually that she request to the university the grade certification to take it to the board of health professionals and apply for the license but the person on charge in the university not evaluate the case still. 4. Review of the job d”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 15884 Based on record reviewed (R.R), policy and interviews, it was determined that the Facility failed to inform to each Medicare recipients “An Important Message from Medicare” (IM) upon admission process and two days before discharge to execute their rights to appeal facility’s discharge, failed to sign, provide the two forms, or provide the second form and inform patients of the IM requirements for 3 out of 45 actives and closed records reviewed (RR. #16, #17 and # 19). Findings include: Facility policy provided by social worker and discharge planning manager (employee #6) on 07/07/2026 at 9:06 AM was reviewed. “Política de Manejo de Admisiones de Pacientes Medicare Tradicional y Medicare Advantage” last review by facility in August 2024 was revised on 07/07/2026, stated that the patient is informed about their appeal rights when admitted to the hospital to receive services and treatment. This policy establishes that the information related to their discharge appeal rights information is going to be provided by admission department. This policy did not include procedures or provisions to be followed to provide discharge appeal rights and process information to patients 48 hours before discharge from hospital. 1. RR #16 is a 65-year-old male Medicare beneficiary who was admitted on 05/27/2026 and discharge on 06/16/26 with a diagnosis of Acute Respiratory Failure. The record was reviewed on 07/08/2026 at 9:42 AM. The clinical record did not evidence that a copy of Medicare Important Message was provided upon admission or 48 hours before discharge. 2. RR #17 is a 94-year-old female Medicare beneficiary who was admitted on 06/01/2026 with a diagnosis of Acute Pneumonia. This patient was discharged with continuity of care to be provided by Hospice on 06/19/2026. The”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 15884 Based on review of documents and the admission packet with the admission manager (employee #34), it was determined that the facility failed to ensure that patient’s rights are promoted regarding update admission packet related to whom they must contact to file a grievance. Findings include: 1. Review of the admission packet provided to the patient at the admission process on 07/08/26 at 9:00 AM, evidence that updated information of the phone number and address for lodging a grievance with the State Agency and the Medicare hot line was not included. 2. The admission department manager (employee #34) was asked by the surveyor, on 07/08/26 at 9:20 AM, the last date where the patient admission package was reviewed. When he looks for it and checks it, the last date when this information was updated was 07/2010. 3. Facility failed to include as part of the patient rights admission package updated telephone number of a representative in the State agency as Assistant Secretary for Regulation of Public Health (SARSP) State Law 101 Division and Medicare Division.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 15884 Based on records reviewed (R.R), Do Not Resuscitate (DNR) Policies and Procedures, it was determined that the facility failed to ensure that patients or their representatives formulate advance directive and comply with these directives related to written DNR or “Do Not Intubate” (DNI) orders and patient’s signed consent for DNR or DNI for 2 out of 45 records reviewed (R.R #23 and #R.R. #45). Findings include: Deficiency practice was identified during the review of cases ( RR #23 ----with Do Not Resuscitate (DNR) and/or Do Not Intubate (DNI) advance directives. A physician order to match DNI/DNR signed consent for DNR/DNI was not found in the medical record. Documentation of the code status were not found documented as part of physician and nurse progress notes and as part of patient plan of care implementation. 1.R.R #23 is an 84-year-old female who was admitted on 07/02/2026 with a diagnosis of Sepsis. On 07/08/2026 at 9:38 AM the record was reviewed with Medical Record clerk (employee #5). It was found that the patient’s representative signed a DNI/DNR consent on 07/02/2026 at 2:25 PM. A physician’s written order of DNI/DNR was not found in the medical record. No evidence was found in the physician progress note of the justification of the DNI/DNR and patient or relative orientation. Medical records do not evidence progress notes documentation by the physician between 07/02/2026 through 07/08/2026 who permit to identify that a discussion was performed with patients and relatives about their preferences regarding resuscitation and DNR/DNI code status. This patient dies on 07/08/2026. 2. R.R #45 is a 62-year-old female who was admitted on 06/17/2026 with a diagnosis of Bilateral Leg Ulcers. On 07/09/2026 at 9:06 AM the record was reviewed with”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 15884 Based observational tour, records reviewed (R.R) and review of policies and procedure, it was determine that the facility failed to promote the patient’s right to be free of restraints and failed to initially and continuously assess and monitor for 6 out of 45 record reviewed (R.R. #11, R.R. #13, R.R. #14, R.R.#16, R.R. #18 and R.R. #25). Findings include: Facility’s policies and procedure related to the physical restraint last revision performed on February 2026 were provided by Institutional Program QAPI officer, (employee #2) 07/08/2026 at 2:00 PM. This policy did not clearly establish responsibilities of the physician in charge of the patient related to ongoing monitoring and documentation of patient status on daily basis or on every physician evaluation and justification for the use of physical restraint. Policy establishes the responsibilities in charge of nursing personnel when providing care to a patient on physical restraint. However, documentation was not found documented as part of every shift nursing progress note and as part of patient plan of care implementation. 1. R. R. #16 is a 65-year-old male who was admitted on 05/27/26 with a diagnosis of Acute Respiratory Failure on Mechanical Ventilation. According to the record review performed on 07/09/26 at 8:30 a.m. with medical record clerk (employee #5), physician order physical restraint on 05/31/26 at 7:50 AM. This order was not signed by nursing personnel in charge of the patient. Progress notes performed by the physician who ordered the physical restraint with justification of the decision to put the patient on restraint were not found documented. Physicians re-order physical restriction to this patient on 05/28/26, 06/01/26,06/03/26, 06/03/26, 06/10/26, 06/1 20423 Review of policy and procedure (P&Ps) performed on 7/09/2026 at 12:00 pm, (P&Ps) Patient Restraint, revised in February 2026, states: XII. Procedure: 1: If an alternative measure is ineffective and immediate restraint is required, the registered nurse will implement it and notify the attending physician to obtain a medical order within one hour. 2. The registered nurse will be responsible for educating the patient and family about the use of the restraint. 3. No more than one hour should elapse before a personal evaluation with the patient and a written order are generated. 4. The evaluation of the indication for restraint will be performed by the attending physician, assigned physician, or on-call physician. They will evaluate the patient to determine whether or not the restraint should continue. 5. The restraint order will be valid for 24 hours. If it is necessary to continue the restraint, a new evaluation and medical order must be obtained. 7. The registered nurse will activate the care plan and reassess it every 24 hours as established by the protocol. 13. Documentation of the restricted patient’s care needs will be completed in the Emergency Room every 30 minutes and for hospitalized patients every hour. XIII. Monitoring: 4. A record will be kept of deaths of restricted patients. 5. Any death that is proven to be related to restriction must be reported to risk management. Risk management will, in turn, notify CMS within seven business days. 3. On 07/09/2026 at 10:30 AM till 4:00 PM review of the four closed records related death with restraint with Electronic Record Coordinator (employee #5), the following was found. a. R.R #11 is a 75-year-old male who was admitted on 04/01/2026 with a diagnosis of Sepsis”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 20423 Based on record review, interview and restraint Policies and Procedures (P&Ps), with Nurse Director (DON) employee #19, it was determined that the facility failed to ensure that the use of restraint be in accordance with physician order for 4 out of 4 death records reviewed (R.R.) with restraint. (R.R. #11, #13, #14, and #25). Findings include: Review of policy and procedure performed on 7/09/2026 at 12:00 pm Policy and Procedure (P&)Patient Restraint, revised in February 2026, states: XII. Procedure: 1: If an alternative measure is ineffective and immediate restraint is required, the registered nurse will implement it and notify the attending physician to obtain a medical order within one hour. 2. The registered nurse will be responsible for educating the patient and family about the use of the restraint. 3. No more than one hour should elapse before a personal evaluation with the patient and a written order are generated. 4. The evaluation of the indication for restraint will be performed by the attending physician, assigned physician, or on-call physician. They will evaluate the patient to determine whether or not the restraint should continue. 5. The restraint order will be valid for 24 hours. If it is necessary to continue the restraint, a new evaluation and medical order must be obtained. 7. The registered nurse will activate the care plan and reassess it every 24 hours as established by the protocol. 13. Documentation of the restricted patient’s care needs will be completed in the Emergency Room every 30 minutes and for hospitalized patients every hour. XIII. Monitoring: 4. A record will be kept of deaths of restricted patients. 5. Any death that is proven to be related to restriction must be reported to risk ma”

“PATIENT RIGHTS: INTERNAL DEATH REPORTING LOG CFR(s): 418.13(g)(2), (3)(ii), (4) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (2) When no seclusion has been used and when the only restraints used on the patient are those applied exclusively to the patient’s wrist(s), and which are composed solely of soft, non-rigid, cloth-like materials, the hospital staff must record in an internal log or other system, the following information: (i) Any death that occurs while a patient is in such restraints. (ii) Any death that occurs within 24 hours after a patient has been removed from such restraints. (3) [The staff must document in the patient’s medical record the date and time the death was:] (i) Recorded in the internal log or other system for deaths described in paragraph (g)(2) of this section. (4) For deaths described in paragraph (g)(2) of this section, entries into the log or other system must be documented as follows: (i) Each entry must be made not later than seven days after the date of death of the patient. (ii) Each entry must document the patient’s name, date of birth, date of death, name of attending physician or other licensed practitioner who is responsible for the care of the patient medical record number, and primary diagnosis(es). (iii) The information must be made available in either written or electronic form to CMS immediately upon request. This Standard is not met as evidenced by: 20423 Based on records reviewed (R.R), interview and restraint Policies and Procedures (P&Ps), with Nurse Director (DON) employee #19, it was determined that the facility failed to ensure that restraint death was reported and maintain in an internal logbook for 4 out of 4 records reviewed (R.R.) death with restraint. (R.R. #11, #13, #14, and #25). Findings include: Review of policy and procedure performed on 7/09/2026 at 12:00 pm Policy and Procedure (P&Ps) Patient Restraint, revised in February 2026, states: XIII. Monitoring: 4. A record will be kept of deaths of restricted patients. 1. On 07/09/2026 at 10:30 AM till 4:00 PM review of the four closed records related to patient death while restraint with Electronic Record Coordinator (employee #5), the following was found. a. R.R #11 is a 75-year-old male who was admitted on 04/01/2026 with a diagnosis of Sepsis, Pneumonia by Aspiration. On 07/09/2026 at 10:30 AM the record was reviewed with the employee #5. It was found that the physician ordered on 04/04/2026 at 7:00 AM Restraint per 24 hours with soft limb, superior extremities right and left due to not cooperating, the patient continue restraint until 04/12/2026 at 7:00 PM that the nurse discontinue the use of restraint. On 04/16/2026 at 7:20 AM, four days later the patient was declared dead by the physician. However, no evidence was found that the Facility maintain an internal logbook to report the death occur 4 days after the patient was release of the restraint. b. R.R #13 is an 87-year-old female who was admitted on 03/29/2026 with a diagnosis of Sepsis. On 07/09/2026 at 11:30 AM the record was reviewed with the employee #5. It was found that the physician ordered on 03/29/2026 at 10:00 PM Restraint per 24 hours w”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 47632 Based on staff interview and review of Quality Assessment and Performance Improvement (QAPI) documentation, it was determined that the Facility failed to ensure the Pharmacy Department and the Catheterization Unit measured, analyzed, and tracked departmental quality indicators to monitor the effectiveness and safety of pharmacy services and catheterization unit services and to support performance improvement activities. Findings include: 1.On 07/09/2026 at 11:45 AM, during an interview, with Director of Pharmacy (employee #13) stated that the Pharmacy Department meets with the Infection Prevention and Quality Departments every two months. During the interview, the surveyor requested documentation demonstrating the analysis, performance measures, trending, and tracking of the Pharmacy Department’s quality indicator presented during the Quality meetings. The Director of Pharmacy was unable to provide evidence demonstrating the analysis, tracking, or follow up of the department quality indicators used to monitor the effectiveness of pharmacy services and support performance improvement activities. 51782 2. Review of the Catheterization Unit quality monitoring on 07/09/2026 at 10:50 AM revealed no evidence that the department was collecting, monitoring, trending, or reporting department specific quality indicators and infection control indicators. During an interview with Catheterization Unit Supervisor (employee #32), on 07/09/206 at 11:07 AM, stated the department maintained only statical information related to the number of procedures performed, physician case volume, and anesthesia utilization. The supervisor stated no department specific quality indicators were monitored or reported. This had the potential to limit the hospital’s ability to identify opportunities for performance improvement and evaluate the quality and safety of services provided in the Catheterization Unit.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 47632 Based on staff interview and review of quality performance monitoring documentation, it was determined that the facility failed to ensure that the Pharmacy Department maintained evidence of the analysis, tracking, and performance monitoring of department quality indicators presented during Quality Assessment and Performance Improvement (QAPI) meeting. Findings include: On 07/09/2026 at 11:45 AM, during an interview, with Director of Pharmacy (employee #13) stated that the Pharmacy Department met with the Infection Prevention and Quality Departments every two months to discuss departmental activities. During the interview, the Director of Pharmacy was asked to provide evidence of the analysis, performance measure, trending, tracking, and follow up of the Pharmacy Department quality meetings. The Director was unable to provide evidence that the department analyzed, monitored, tracked or evaluated the effectiveness of the indicators or the results were used to implement and monitor performance improvement activities.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 20423 Based on credential file review, interview with facility Acting director of nursing (employee #19), and human resources employee (employee #7), it was determined that the facility failed to have a well-organized nursing service to ensure the quality of the patient care provided by the nursing service. This deficient practice had the potential to affect 46 out of 46 patients admitted receiving services. Findings include: 1. Review of credential file of the Director of Nursing (DON) of the facility on 07/09/206 at 9:50 AM with human resources (employee #7) evidence that the person that is on Acting position since March 19, 2018. 2. Human resource (employee #7) was asked on 07/09/2026 at 10:00 AM if there is a requirement by the facility that the DON of the facility had a master’s degree in nursing with concentration in nursing administration services, she stated that it is highly recommended to comply with Puerto Rico (PR) State Law # 254 of December 31, 2015, who regulates the nursing practice in PR. No evidence was found on the Acting director of nursing credential file that she had a master’s in nursing with concentration in nursing administration services. They only evidence that this employee had a bachelor’s degree in nursing. 3. Facility Acting director of nursing (employee #19), was asked on 09/09/2026 at 10:30 AM if she had a master’s degree in nursing with concentration in nursing administration services. She stated that she has a master’s degree in nursing with concentration in nursing administration services since 2018 but she had not made arrangements to acquire the nursing specialized license and credentials, since actually that she request to the university the grade certification to take it to the board of health professionals and apply for th”

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 20423 Based on the review of fifteen nursing credential files (C.F’s), it was determined that the facility failed to ensure that seven personnel are licensed in accordance with state and local laws related to Nursing degree, Influenza Vaccine, Annual Evaluation, and Duties/ Functions for 7 out 15 C.Fs (C.Fs #1, #2, #3, #5, #7, #9, and #10 ). Findings include: 1. Fifteen nursing credential files were reviewed with the Human Recourse Director (employee #7) on 7/9/2026 at 9:50 AM through 12:30 PM provided evidence of the following: a. Seven out of fifteen nursing credential files that were supervisors did not have evidence of a Nursing master’s degree accordance to Law No. 254 of December 31, 2015, “Law to Regulate the Practice of Nursing.” and Regulation No. 9104 of August 9, 2019, “Regulating the Nursing Profession in Puerto Rico” (C.F. # 1, #2, #3, #5, #7. #9 and #10). b. One out of fifteen nursing credential file did not have evidence of Influenza vaccines or refuse certification, accordance to state administrative order #244 of 10/10/2008 of the Department of health and the state administrative order #362 of 12/8/16 of the Department of health (N.C.F #9).”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 20423 Based on records reviewed, interview and restraint Policies and Procedures (P&Ps), with Nurse Director (DON) employee #19, it was determined that the facility failed to ensure that nursing staff develops, implement and update nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs related to restraint for 4 out of 4 records reviewed (R.R.) with restraint. (R.R. #11, #13, #14, and #25). Findings include: Review of P&Ps performed on 7/09/2026 at 12:00 pm for Patient Restraint, revised in February 2026, states: XII. Procedure: 7. The registered nurse will activate the care plan and reassess it every 24 hours as established by the protocol. 1. On 07/09/2026 at 10:30 AM till 4:00 PM review of the four closed records related to patient restraint with Electronic Record Coordinator (employee #5), the following was found. a. R.R #11 is a 75-year-old male who was admitted on 04/01/2026 with a diagnosis of Sepsis, Pneumonia by Aspiration. On 07/09/2026 at 10:30 AM the record was reviewed with the employee #5. It was found that the physician ordered on 04/04/2026 at 7:00 AM Restraint per 24 hours with soft limb, superior extremities right and left due to not cooperating. No evidence was found that the registered Nurse developed and update the restraint plan of care. No evidence was found that the registered nurses documented her progress and note the implementation of the restraint care plan. b. R.R #13 is an 87-year-old female who was admitted on 03/29/2026 with a diagnosis of Sepsis. On 07/09/2026 at 11:30 AM the record was reviewed with the employee #5. It was found that the physician ordered on 03/29/2026 at 10:00 PM Restraint per 24 hours with soft limb”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 51629 Based on interviews with the Nutritional Services Supervisor (employee # 14), Medicine Ward Nursing Supervisor (employee # 16) and records reviewed (RR) performed on 07/08/2026 from 8:30 AM to 11:30 AM, it was determined that the facility failed to meet individual patient nutritional needs in accordance with recognized dietary practices. This deficient practice was observed in 6 out of 6 records reviewed (RR#1, # 4, # 6, # 21, # 42 and # 43). Findings include: 1. During interview with Nutritional Services Supervisor (employee # 14), Medicine Ward Nursing Supervisor (employee # 16) and records reviewed performed on 07/07/26 at 2:00 PM and 07/08/2026 from 8:30 AM to 11:30 AM, they stated that during the admission process, a nutritional risk assessment is performed by the registered nurse (RN). It is done to identify risks and proceed to notify the nutritionist for a more detailed nutritional assessment. The nutritional risk assessment to be performed by the RN is documented in the electronic health record, template named: Initial Nursing Assessment. 2. The policy named: “Orden de Dieta” -Diet Order (June/2026 revision) was reviewed on 07/08/2026 at 1:30 PM. The facility policy states (procedure section, 4) that during admission, the registered nurse (RN) will perform a nutritional risk assessment and consult nutritionist if the patient has two or more nutritional risks as specified in the policy. 3. RR # 1 is a 49-year-old male who was admitted on 06/28/2026 with a diagnosis of Laryngeal mass and Pneumonia. During record review performed on 07/07/2026 at 2:00 PM, the patient was still hospitalized but the clinical record did not evidence a nutritional risk assessment performed by the RN. Also, the manual clinical record contains a document named: “Grupo de Alimentos”- F”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 47384 Based on observation performed on 07/07/2026 through 07/08/2026, it was determined that the facility failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured. Findings include: 1. Ceiling tiles with water damage on the anesthesia supply room on the Surgery Ward. 2. Ceiling tiles with water damage on the hallway area outside anesthesia supply area. 3. Surgery room doors in suites B, C, D were observed whit steel cover plates in need of repair. 4. The entrance door to the autoclave area was seen misaligned, which allows entry of plant material (leaves). 5. Ceiling tiles with water damage on the ambu;lance enmtrance area in the Emergency Ward. 6. Air condition (AC) vent observed with black mold like spots in front of Cardio cubicle #2 in the Emergency Ward. 7. Emergency Ward Isolation room door was foud not to close flush. 8. Walls with peeling paint found in the Emergency Ward Isolation room. 9. Nurses station in Emergency Ward was found with broken formica. 10. Air condition (AC) vent observed with black mold like spots in MRI area. 11. Air condition (AC) vent observed with excesive dust in CT area. 12. Medical gas tank storage room was observed with not adecuate metal mesh to inpeed acces to area. 13. Vinyl floor was observed broken in front of room #422. 14. Broken Stergis Surgical lamp was observed in Surgery suite A. 15. Rust was observed in all (4) Stergis Surgical lamps, it was stated to the Surgery Ward supervisor and explained this was caused by the chemicals used for cleaning. 16. Rust was ob 47632 19. On 07/08/2026 at 8:59 AM, during a tour of the Pediatric Emergency Department, observed that the negative pressure ventilation system in the designated isolation room was not operating. At the time of the observation, the Emergency Department Coordinator (employee #11) stated that the negative pressure ventilation system was controlled by an on/off switch. It was observed that the switch controlling the negative pressure ventilation system was in the “off” position, rendering the negative pressure system non operational. The facility failed to ensure that the designated airbone isolation room was maintaied in operational condition to provide the required negative pressure enviroment for patients requiring airbone. 51782 20. During the operating room areas and endoscopy areas tour performed on 07/07/2025 through 07/08/2026 from 9:00 AM till 3:30 PM accompanied by the operating room supervisor (employee #27) the following was observed: a) On 07/07/2026 at 9:32 AM in the pathology room: -Ceiling acoustics with noticeable appearance of humidity and filtration. b) On 07/07/2026 at 11:45 AM in the surgery room, suite A: -Three surgical table wheels with extensive mold. c) On 07/07/2026 at 1:55 PM in the surgery room, suite C: -Surgical table wheels with extensive mold. -Metal stand wheels, where red biohazard bags are placed, with extensive mold. -Red trash can stand with mold. -Metal chair wheels with mold. d) On 07/07/2026 at 3:04 PM in surgery room, suite B: -Window frame with abundant mold. -Blue shelf edge with mold. e) On 07/08/2026 at 9:00 AM in the disinfection room, endoscopy unit: - Water hardness residue in the eyewash station. - Counter where the sink is located, with mold. f) On 07/08/2026 at 9:15 AM in the endoscopy unit: - The floor of the hallway in front of the disinfection room was stained and appearance like dirty. 51829 21. On 07/07/2026 at 10:02 AM, accompanied by the Emergency Department Coordinator (Employee #11), a former supply room-now used to store wheelchairs-was inspected. Mold was observed in the air duct; additionally, while the temperature should be 72°F, it registered at 70°F. Humidity levels should range between 30% and 60%, yet the room measured 64% humidity. 22. On 07/07/2026 at 11:03 AM, accompanied by the Emergency Department Coordinator (Employee #11), it was noted that the bathroom in the adult isolation room located within the Emergency Department lacked a nurse call system. 51629 23. During the kitchen tour performed on 07/07/2025 from 9:40 AM till 12:00 PM accompanied by the Nutritional Services Supervisor (employee # 14) the following was observed: a. Dry food storage area - Wall behind the door with peeling paint. b. Tray washing area - Broken tiles on the floor.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 07/07/2026 through 07/08/2026 from 8:00 AM to 4:00 PM with the facility’s Physical Plant Supervisor (employee #8), it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101. Findings include: The Life Safety from Fire survey was performed on 07/07/2026 through 07/08/2026, for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS2567 form ( K225, K291, K293, K321, K324, K345, K353, K354, K372, K751, K753, K781, K907, K912, K920 , K921, K922, K923).”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 51629 Based on observations made on 07/07/2025 from 9:40 AM till 12:00 PM, it was identified that the facility failed to ensure an acceptable level of safety in facilities, supplies and equipment. Findings include: 1. During the kitchen tour performed on 07/07/2025 from 9:40 AM till 12:00 PM accompanied by the Nutritional Services Supervisor (employee # 14) the following was observed: a. Carbon dioxide tank (without a base to hold it) placed in front of the door to keep it open. b. The walk-in freezer with the entrance floor all covered with ice, slippery. Only the entrance had rubber floor mats. c. Ice machine area: “ The receptacle where it is connected is not ground fault. d. Three tray transport carts blocking the doors to the air conditioning room and electrical panel room. 2. During the radiology department tour performed on 07/09/2026 from 9:30 AM to 10:30 AM accompanied by the Imaging Center Supervisor (employee #15), the following was observed: a. Crash cart located in the radiology ward without a defibrillator. b. Signs with the evacuation route were not posted on the walls. The facility failed to ensure an acceptable level of safety in facilities, supplies and equipment.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47632 Based on observation, interview, and documentation reviewed, it was determined that the facility failed to ensure to perform hand hygiene, safe injection practices, disinfect reusable patient care equipment, airborne isolation precautions and the availability of personal protective equipment (PPE) in an isolation room, failed to provide standards for infection control related to preventing and controlling the transmission of infections within the hospital after observational tours, review policies and interviews performed in the operating room and catheterization unit. Findings include: On 07/08/2026, from 8:55 AM through 12:00 PM, during a tour of the Adult and pediatric Emergency Department, Radiology Department, East Medical Unit, and West Medical Unit, accompanied by the Infection Prevention and Control Nurse, the following observations were made: 1. Adult Emergency Department: a. In the isolation area, the negative pressure ventilation duct grille was observed with an accumulation of dust. 2. Pediatric Emergency Department: a. In the isolation area, was observed that the negative pressure ventilation system in the designated isolated isolation room. At the time of the observation with the Emergency Department Coordinator (employee #11) stated that the negative pressure ventilation system was controlled by an on/off switch. It was observed that the switch controlling the negative pressure ventilation system was in the “off” position, rendering the negative pressure system nonoperational. 3. Radiology Department: a. Registered Nurse (employee #39) was observed obtaining vital signs of a patient without wearing gloves. Following completion of the procedure, the nurse failed to disinfect the blood pressure cuff before and after s 51782 Facility policy provided by Operating Room Supervisor (employee #27), on 07/08/2026 at 10:38 AM was reviewed. “Manejo de Material Expirado en Suministro Esteriles” -“Handling Expired Material in Sterile Supplies”. The policy states on page 1, section 1 that a date will be assigned to evaluate the material weekly. If the package is a bag, it will have an effective period of three months; if the instrument is not in high demand, it will be four months. 5. During the round made with the Operating Room Supervisor (employee #27) in the operating room department areas, the following was observed: a) On 07/07/2026 at 10:25 AM, in the recovery room six lower body thermal blankets expired on 05/31/2026. b) On 07/07/2026 at 11:20 AM in the sterile storage twenty-one packaged sterile instruments such as forceps and speculums expired on 05/2026. 6. During the round made with the Catheterization Unit Supervisor (employee #32) in the catheterization unit areas, the following was observed: Facility policy provided by Catheterization Unit Supervisor (employee #32), on 07/09/2026 at 2:05 PM was reviewed. “Fecha de Experiración y/o Fecha de Máximo Uso (Beyond use Dates)” -“Expiration Date and/or Maximum Use Date (Beyond use Dates)”. The policy states on page 1, section 1 that for commercially available unit-dose products, their maximum use date (beyond use date) will be established by the manufacturer as the expiration date, provided that the storage and handling requirements established by the manufacturer have been met. Facility policy provided by Catheterization Unit Supervisor (employee #32), on 07/09/2026 at 2:05 PM was reviewed. “Almacenamiento de Medicamentos” -“Drug Storage” The policy states on page 2, section 11, that the”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47632 Based on interviews and documents reviewed, it was determined that the facility failed to ensure all hospital departments reported Infection Prevention and Control indicator, including established performance goals, data analysis, and corrective and Control Program and failed to provide a clean and sanitary environment to avoid sources and transmission of infection. Findings include: On 07/07/2026 at 2:06 PM, during an interview with the Infection Prevention and Control Nurse (employee #1), she stated that the Emergency Department, Intensive Care Unit, East Medical Unit, and West Medical Unit did not report Infection Prevention and Control indicators to the Infection Prevention and Control Program. She further stated that these departments did not submit indicators with established goals, data analysis, or corrective action plans. 1. The Facility failed to ensure that all hospital departments reported Infection Prevention Control Program indicators to Infection Prevention Control Program as part of the hospital wide surveillance process. 51629 2. During the kitchen tour performed on 07/07/2025 from 9:40 AM till 12:00 PM accompanied by the Nutritional Services Supervisor (employee # 14) the following was observed: a. Cabinet next to the sink at the entrance to the kitchen, with deteriorated Formica. b. Dry food storage area “Two open containers with Hunny Glaze and Flat Icing Chocolate respectively, without any sign indicating the date it was opened. “A spiderweb at the back of the storage area, crossing from one rack to another. “Three broken Quik chocolate powder containers. c.Walk in freezer “Tray with pastry templates inside, with the cover broken by the weight of ice fragments on it and not dated. “Two boxes of imitation crab meat, with the cover broken by the weight of ice fragments on it and not dated. “Four boxes of plantain chips on the floor. d. An industrial mixer with mold on several of its components. e. Rack where gallons of oil are placed, with oil residue all over the rack. f. Food warmer with heat escape in the doors. g. Ten plastic trays, deteriorated and broken h.Tray washing area “Mold in the compartments where the trays are placed “Broken tiles on the floor. i. Deteriorated choppers (cutting boards) of different sizes. j. Blackened and gouged pots. k.Two knives caught between the wall and the edge of the stainless steel furniture. The facility failed to provide a clean and sanitary environment to avoid sources and transmission of infection.”

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 51829 Based on observations and interviews, accompanied by the Emergency Department Coordinator (employee #11), it was determined that the facilities did not ensure adherence to best practices regarding prevention, patient safety, and infection control aimed at preventing and minimizing infections. Findings include: 1. On 07/08/2026 at 1:00 PM, an interview with the Emergency Department Coordinator (Employee #11) revealed that she had not been assigned specific infection control indicators to implement. a. She tracks quality indicators related to patient transfers, elopements, Against Medical Advice (AMA) discharges, and the use of restraints (per established protocols); reports are submitted, discussed, and shared with staff, and where education or support is warranted-these are provided and documented. b. She conducts annual competency assessments (covering topics such as the use of personal protective equipment and hand hygiene) and includes infection control as a mandatory educational topic annually, maintaining records of this training. 2. Indicators are established in the hospital regulations; infection control regulations mandate the development and implementation of policies for infection surveillance, prevention, and control throughout the hospital, including the Emergency Department.”

“WRITTEN POLICIES AND PROCEDURES CFR(s): 482.45(a) The hospital must have and implement written protocols that: This Standard is not met as evidenced by: 20423 Based on review of policy and procedures (P&Ps) on 07/09/2026 at 1:30 PM, it was determined that the facility failed to ensure the governing body approve written P&Ps and protocols for organ procurement. Findings include: On 07/09/2026 at 1:00 PM review the facility’s P&Ps Identification of Organ and Tissue Donors revised in August 2024, during the review it was identified that the facility failed to define Imminent death in the policy.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 51782 Based on document review, policies and procedure review and staff interviews, the hospital failed to ensure complete documentation operating rooms were cleaned between procedure, and terminal cleaning activities were documented. Findings include: Facility policy provided by Operating Room Supervisor (employee #27), on 07/08/2026 at 10:25 AM, was reviewed. “Limpieza de Sala de Operaciones” - “Operating Room Cleaning”. The policy states on page 2, section 4, that daily, between cases, all surfaces that came into contact with the patient must be cleaned, including IV stands and chairs for both the anesthesia and registered nurses, before mapping the floor, the door lock must be cleaned upon leaving. Section #5 mentions that daily, at the end of the case schedule, maintenance personnel will perform a terminal cleaning of all rooms. 1. Review of the Operating Room Schedule log and the Environmental Services Cleaning log for April, May and June 2026 revealed surgical procedures were performed on the following dates; however, the environmental services cleaning log did not contain documentation that the cleaning between procedures had been on those dates: a) April 1, 2, 6, 7, 8, 9, 10, 13, 14, 15, 16 and 27, 2026. b) May 18, 27, 28 and 29, 2026. c) June 3, 4, 9, 10, 11, 16, 17, 18, 19, 20, 25 and 26, 2026. 2. Review of the Operating Room Schedule log and the Environmental Services Cleaning log for April, May and June 2026 revealed surgical procedures were performed; however, the environmental services cleaning log did not contain documentation that the terminal cleaning on the operating rooms had been on those months. During an interview on 07/08/2026 at 9:45 AM the operating room supervisor (employee #27), stated operating rooms are clean”

“REQUIRED OPERATING ROOM EQUIPMENT CFR(s): 482.51(b)(3) The following equipment must be available to the operating room suites: call-in system, cardiac monitor, resuscitator, defibrillator, aspirator, and tracheotomy set. This Standard is not met as evidenced by: 51782 Based on observations made in the operating room recovery area on 07/07/2026, it was determined that the facility failed to ensure that biomedical equipment was inspected, tested, and maintained. Findings include: 1. During observations made in the recovery area with the operating supervisor (employee #27) on 07/07/2025 from 9:40 AM to 10:15 AM, the following were found: a. The defibrillator monitor on the emergency cart was found to have an expired inspection/maintenance seal (04/2026). b. The cardiac monitor located in cubicle #5, was found to have an expired inspection/maintenance seal (06/2026). During an interview with the operating room supervisor (employee #27), she makes a phone call to the biomedical personnel who mentions that they are in the process of performing the inspections.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 07/08/2026 from 1:00 PM through 2:15 PM, to evaluate emergency preparedness requirements, it was determined that the Facility failed to include revisions to their emergency preparedness plans, Emerging Infectious Deseases (EID’s) are a potential threat which can impact the operations and continuity of care within a healthcare setting and should be considered. Findings include: During the review of the facilities Emergency Preparedness Program, it was noted that the facility failed to include emerging infectious diseases (Influenza, Ebola, Zika, etc.) in the Emergency Plan.”

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 47384 Based on facility documents reviewed for Emergency Preparedness Program (EPP) requirements, it was determined that the Facility failed to specify the population served within the Facility, such as inpatients and/or outpatients, and their unique vulnerabilities in the event of an emergency or disaster. Findings include: During the review of the facilities Emergency Preparedness Program on 07/08/2026, it was noted that the facility failed to address the ability of providing services to patients during emergencies, continuity of operations, delegation of authorities and succession plans.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 07/08/2026, to evaluate emergency preparedness requirements, it was determined that the Facility failed to develop procedures to track the location of on-duty staff and sheltered patients in the facility’s care during and an emergency. Findings include: During the review of the facilities Emergency Preparedness Program, it was noted that the EP failed to have written procedures to document the specific name and location of the receiving facility or other location or how to track patients and staff.”

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 07/08/2026, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide means to shelter in place for patients, staff and volunteers who remain in the facility. Findings include: During the review of the facilities Emergency Preparedness Program, it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the unit during and after an emergency.”

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 07/08/2026, to evaluate emergency preparedness requirements, it was determined that the Facility failed to have policies and procedures describing the system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records. Findings include: During the review of the facilities Emergency Preparedness Program, it was noted that the EP failed to have written process for preserving patient information.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 07/08/2026, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain policies and procedures related with the role of the facility under a waiver declared by the Secretary in accordance with section 1135 of the Act in the provision of care and treatment. Findings include: During the review of the Emergency Preparedness Program, it was noted that the EP failed to include policies and procedures which outline the facility’s role in the provision of care and treatment under section 1135 waivers during a declared public health emergency.”

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 07/08/2026, it was determined that the facility failed to include means of providing information about the general condition and location of patients under the facility’s care. Findings include: During the review of the Emergency Preparedness Program, it was noted that the EP failed to include means of providing information about the general condition and location of patients under the facility’s care to ensure continuity of services.”

“Information on Occupancy/Needs CFR(s): §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: 47384 Based on an Emergency Preparedness Program (EPP) survey performed on 07/08/2026, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to have means of providing information about the facility’s occupancy, needs, and its ability to aid during an emergency. Findings include: During the review of the facilities Emergency Preparedness Program, it was noted that the facility failed to have written procedures for providing information about the facility’s occupancy, needs, and its ability to aid, to the authority having jurisdiction, the Incident Command Center, or designee.”

“Based on tests to equipment, interviews and observations made during the survey for Life Safety from Fire on July 07, 2026 through July 08, 2026, it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101. Type of Structure: one (5) story building, Type I (443) and Type II (222) , protected non-combustible construction with one (2) smoke compartment and partially sprinkled (wet) sprinkler system. The findings that follow demonstrate noncompliance with Title 42, Code of Federal Regulations (Life Safety from Fire). Census: 46 Licensed beds: 183”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire of the Facility on 07/07/2026 through 07/08/2026 from 8:00 AM through 3:00 PM, it was determined that the Facility failed to ensure that Stairways are in accordance with 7.2. Findings include: On 07/08/2026 at approximately 10:15 AM it was observed that the stairway serving as exit route was found with exesive vegetative material (leaves and flowers) on steps and landings. This can cause water acumulation and represents a slip hazard even when not wet. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire of the Facility on 07/07/2026 through 07/08/2026 from 8:00 AM through 3:00 PM, it was determined that the Facility failed to ensure emergency lighting in accordance with 7.9, 18.2.9.1, 19.2.9. Findings include: 1. On 07/07/2026 at approximately 8:45 AM it was noticed that no battery backup emergency light were present on the mechanical room (chiller room - fire pump room). 2. On 07/07/2026 at approximately 8:55 AM it was noticed that no battery backup emergency light were present on basement floor hallway that leads to the south side exit. 3. On 07/07/2026 at approximately 9:25 PM it was noticed that no battery backup emergency light were present outside the exit door of the south side exit. 4. On 07/07/2026 at approximately 1:35 PM it was noticed that one lamps of a battery backup emergency light was broken on the waiting area of the emergency ward (ER). 5. On 07/07/2026 at approximately 1:55 PM it was noticed that one lamp of the battery backup emergency light on the ER was found not operating. 6. On 07/08/2026 at approximately 9:08 AM it was noticed that no battery backup emergency light above the 2 Mega generator. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire from 07/07/2026 through 07/08/2026, it was determined that the facility failed to maintain exit and directional signs displayed in accordance with 7.10. Findings include: 1) During observation of the Mechanical room, it was noticed that two (2) exit sings were needed to state obvious exit from the inside the Mechanical Room. 2) During observation of the hallway leading to the mechanical room, it was noticed that the existing exit sing was not operational. 3) During observation of the kitchen area, it was noticed that the exit sing next to the walk-in coolers was not operational. 4) During observation of the Information Management area, it was noticed that five (5) exit sings should be installed in this area in order to state obvious exit from the inside to exit pathway. (three (3) in the file area, one (1) in personnel area, one (1) main entrance area). 5) During observation of the Laboratory, it was noticed that the exit sing on main hallway should be relocated closer to the door in order to state obvious exit pathway. 6) During observation of the Laboratory, it was noticed that no exit sing was present on the lounge area to state obvious exit payhway. 7) During observation of the Emergency Ward, it was noticed that the exit sing on the waiting arae was not operational. 8) During observation of the Emergency Ward, it was noticed that one (1) exit sing was needed to state obvious exit in the ambulance entrance hallway. 9) During observation of the fourth floor, it was noticed that one (1) exit sing was needed to state obvious exit in the hallway in fromt of Residents (doctors) room. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 47384 Based on observation, interview, and record review, the facility failed to provide the required protection for a hazardous mechanical room adjacent to a patient care area in accordance with NFPA 101 (2012 Edition). This deficient practice could permit the spread of smoke and fire into the adjacent Intensive Care Unit (ICU), potentially delaying evacuation and placing patients, staff, and visitors at risk. Findings include: During observation conducted on July 8, 2026, in the presence of the Physical Plant Supervisor (employee #8), the air conditioning mechanical room located adjacent to the Intensive Care Unit (ICU) station #8 was observed to have wall construction that did not extend continuously from the floor to the underside of the floor or roof deck above, leaving the ceiling plenum open between the mechanical room and the adjacent areas. The mechanical room was not provided with smoke detection. Interview with the Physical Plant Supervisor (employee #8) confirmed the wall did not provide a complete fire-resistance-rated enclosure and acknowledged that smoke detection was not installed within the mechanical room.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for life safety from fire with the facility’s Physichal Plant Supervisor (Employee #8), the facility failed to visually inspect and maintain fire suppression manual release in accordance with the requirements NFPA 101, 2012 Edition, Section 19.3.2.5.1 through 19.3.2.5.4 and 9.2.3 and NFPA 96, 2011 Edition. Findings include: 1) During observational tour of the kitchen area approximately at 11:15 AM it was noticed that the manual activation device (pull station) for the ANSUL System lacked monthly inspection signatures on the inspection card. Last monthly inspection recorded on card was 02/03/2025. 2) During observational tour of the kitchen area approximately at 11:15 AM it was noticed that the manual activation device (pull station) for the ANSUL System pull handle was observed with corrosion. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 47384 Based on observation and interview, the facility failed to ensure the fire alarm was properly managed in accordance with NFPA 72, 2010 Edition, Section 10.19, and NFPA 101, 2012 Edition, Section 9.6.1.6, by failing to maintain all devices in operational condition. Findings include: During observation of the Generator #1 and #2 area it was identified that a smoke detector was not operational, upon verificataion of the fire alarm pannel it was noticed that no trouble signal or alarm was notified on the pannel. The finding was verified by the Physichal Plant Supervisor at the time of the observation.”

“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: 47384 Based on observation and interview, the facility failed to maintain components of the fire protection system in accordance with NFPA 25 requirements. Findings include: 1) Based on interview and record review performed on 07/09/2026 approximately alt 9:10 AM it was noticed that there was no documentation provided regarding the sprinkler piping internal inspection, pressure gauges on the sprinkler main were replaced or tested by comparison with a calibrated gage within the last five years (2017). 2) During the observation carried out in the mechanical room, a leak was identified in the fire pump. The physical plant Supervisor (employee #8) was aware and could show actions taken through a service order requested, but at the time of the survey, it had not been fixed. 3) Loaded sprinklers and corroded were observed on the hallway area leading to the mechanical room. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 47384 Based on observation, interview, and record review, the facility failed to maintain a fixed gaseous fire suppression system in an operational condition in accordance with applicable NFPA standards. This deficient practice could delay or prevent automatic fire suppression within the medical records room, increasing the potential for fire growth and loss of critical patient records. Findings include: During the Life Safety Code survey, observation of the medical records room revealed the installed hypoxic gaseous fire suppression system had previously deployed and had not been restored to service. Interview with the Physical Plant Supervisor confirmed the system had discharged and remained out of service at the time of the survey. No documentation was provided demonstrating the system had been repaired, recharged, or returned to operational status, leaving the protected area without its intended automatic gaseous fire suppression capability. No evidence of interin safety measure was provided during survey. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 47384 Based on observation and interview, the facility failed to maintain smoke barrier doors to resist the passage of smoke in accordance with NFPA 101 (2012) requirements. This deficient practice could allow the migration of smoke between smoke compartments during a fire emergency, potentially affecting the safety of patients, staff, and visitors. Findings include: 1. On 07/08/2026, observation on the third floor revealed the smoke barrier door located between Rooms 326 and 327 had a clearance gap exceeding 1/8 inch at the meeting edge. The excessive gap could permit the passage of smoke through the smoke barrier. Interview with the Facility Director at the time of the observation confirmed the condition. 2. On 07/08/2026, observation on the second floor, at the smoke barrier doors located in front of the Chapel, revealed the magnetic hold-open release device required adjustment. During testing, the magnetic release device did not properly release the smoke barrier doors to allow them to close completely upon activation. Interview with the Facility Director confirmed the magnetic release device was not operating as intended and required adjustment to ensure proper automatic closure of the smoke barrier doors.”

“Draperies, Curtains, and Loosely Hanging Fabr CFR(s): NFPA 101 Draperies, Curtains, and Loosely Hanging Fabrics Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall. 18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire with the facility’s Physical Plant Supervisor (Employee #8), it was determined that the facility failed to certify that dividing curtains are up to standard with NFPA 701 in accordance with 10.3.1. Findings include: During observational tour on faclity’s Recovery area in the Surgery Department it was noticed that seven (7) curtains had no tags for flame retardant or fire resistant regulation in accordance with an equivalent standard to NFPA 701. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Combustible Decorations CFR(s): NFPA 101 Combustible Decorations Combustible decorations shall be prohibited unless one of the following is met: o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product. o Decorations meet NFPA 701. o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289. o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present. 19.7.5.6 This Standard is not met as evidenced by: 47384 Based on observation and interview, the facility failed to ensure combustible decorations were maintained in accordance with NFPA 101 requirements. This deficient practice could contribute to the rapid spread of fire and smoke in patient care areas, increasing the risk to patients, staff, and visitors. Findings include: During observations conducted on July 8, 2026, in the presence of the Physical Plant Supervisor (employee #8), combustible decorative materials were observed in patient care areas as follows: 1) The Computed Tomography (CT) Department contained combustible decorative materials affixed to ceiling. 2) The Radiology Department contained combustible decorative materials that had not been demonstrated to be flame-retardant or otherwise compliant with the requirements for interior decorations. 3) The Intensive Care Unit (ICU) contained combustible decorative materials displayed within the patient care area. Interview with the Physical Plant Supervisor (employee #8) confirmed that the decorative materials had not been evaluated or treated to meet the applicable flame-resistance requirements and acknowledged the findings at the time of the survey. The facility failed to ensure combustible decorations were limited or maintained in accordance with the Life Safety Code, thereby increasing the potential for fire growth and smoke development within patient care areas. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 07/07/2026 through 07/08/2026 from 8:00 AM to 3:00 PM with the facility’s Physical Plant Supervisor (Employee #8), it was determined that the facility failed to maintain areas free of portable space heating devices. 18.7.8, 19.7.8 Findings include: 1. Two (2) Portable heaters was obseverd on the Emergency Ward Supervisor office. 2. Portable heater was obseverd on Intensive Care Unit Supervisor office. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observation and interview, the facility failed to maintain the medical gas central supply system zone valve box serving Operating Rooms B and C in accordance with NFPA 99 requirements. This deficient practice could permit inadvertent operation or unauthorized manipulation of the medical gas emergency shutoff valve, resulting in an unintended interruption of medical gas service to the operating rooms and placing surgical patients at risk. Findings include: During observation of the Surgery Department, the medical gas central supply system zone valve box located adjacent to Operating Rooms B and C was observed to be missing the required protective transparent breakable/removable cover. The emergency shutoff valves were exposed and were not protected from accidental operation or unauthorized tampering while still permitting immediate access during an emergency. The Physical Plant Supervisor confirmed the protective cover was missing and acknowledged the finding at the time of the survey. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 04/28/2025, it was determined that the facility failed to maintain electrical safety as required in 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) Findings include: 1) During observation of the Surgery Ward and record review, it was identified that the electrical receptacle inspection was last performed in December 2025. The inspection label affixed to both the normal power receptacles and red emergency (standby power) receptacles indicated the next inspection was due in June 2026. At the time of the survey, the required inspections had not been completed, and the facility was unable to provide documentation demonstrating that the receptacles had been tested in accordance with the facility’s documented maintenance program. 2) During observation of the Information Management area and record review, it was identified that the electrical receptacle inspection was last performed in August 2024. The inspection label affixed to both the normal power receptacles and red emergency (standby power) receptacles indicated the next inspection was due in August 2025. At the time of the survey, the required inspections were overdue, and the facility was unable to provide documentation demonstrating compliance with the facility’s documented performance testing program. 3) During observation of the Laboratory, Urinalisis area it was noticed that the recepatacle next to the labatory was not a ground-fault circuit interrupters (GFCI) and should be replaced. 4) During observation of the kitchen area, ice machine recepatacle was not a ground-fault circuit interrupters (GFCI) and should be replaced 5) During observation of the Dialisis area, treatment machine recepatacles were not a ground-fault circuit interrupters (GFCI) and should be replaced. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire from 07/07/2026 through 07/08/2026, it was determined that the facility failed to have Hospital grade power cords or multy-plugs in clinical areas as required in 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5. Findings include: Non-Hospital Grade multy-plugs and extension cords were found in: 1. One (1) Non-Hospital Grade multy-plug in Surgery Room A. 2. Two (2) Non-Hospital Grade multy-plug in Surgery Room B. 3. Two (2) Non-Hospital Grade multy-plug in Surgery Room C. 4. One (1) Non-Hospital Grade multy-plug on Surgery Room D. 5. One (1) commercial grade orange extension cord found connected to the battery charger for the 2 Mega generators. Plug was found to be missing the ground post. 6. One (1) Non-Hospital Grade multy-plug found on the surgical equipment warehouse. 7. One (1) commercial grade extension cord on MRI technical area. 8. One (1) Non-Hospital Grade multy-plug found on the nurse’s station on third floor. 9. One (1) in-house fabricated extension cord on lounge area on the Surgery Ward. 10. One (1) Non-Hospital Grade multy-plug in CT room. 11. One (1) in-house fabricated extension cord on lounge area on the Laboratory Ward lounge. 12. One (1) Non-Hospital Grade multy-plug in lounge area on the Laboratory Ward lounge. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Electrical Equipment - Testing and Maintenanc CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility’s policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This Standard is not met as evidenced by: 47384 Based on observation and interview, the facility failed to ensure electrical equipment and resident care-related electrical devices were maintained in safe operating condition in accordance with NFPA 99, 2012 Edition, Section 10.2.4 and NFPA 70 (National Electrical Code), by allowing damaged, modified, and improperly maintained power cords and electrical connections. Findings include: During the survey of residents rooms, the following electrical hazards were observed: 1. In 12 out of 28 rooms, modified power plugs were observed with no strain relief at the cable-to-plug connection. The cord was pinched at the connection point, creating stress on the electrical wiring. 2. Broken electrical power cord was observed on Ergotron machine on Surgery room D. 3. Modified power plug were observed with no strain relief at the cable-to-plug connection in the Laboratory Ward behind the Ortho Clinical Diagnostic Machine. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Gas Equipment - Other CFR(s): NFPA 101 Gas Equipment - Other List in the REMARKS section any NFPA 99 Chapter 11 Gas Equipment 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 11 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observation and interview, the facility failed to ensure compressed medical gas cylinders were properly secured to prevent accidental tipping or falling in accordance with NFPA 99 requirements. This deficient practice could result in cylinder damage, uncontrolled release of compressed oxygen, or injury to patients, staff, and visitors. Findings include: During observation conducted on July 9, 2026, at approximately 10:00 a.m., in the Medication Room of the Catheterization Ward, two (2) Type E oxygen cylinders were observed standing upright and not secured with chains, straps, racks, or other approved means to prevent tipping or falling. The cylinders were stored without any form of fall protection. Interview with the Cateterism area Supervisor confirmed the cylinders were unsecured at the time of the observation and acknowledged the finding. Reference: NFPA 99, 2012 Edition, Section 11.6.2, which requires compressed gas cylinders in storage or in use to be protected from accidental damage and secured to prevent them from falling or being knocked over. The findings were verified by the Physical Plant Supervisor at the time of the observation.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 07/08/2026, it was determined that the facility failed to maintain the medical gas cylinder area as required in 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99). Findings include: During a tour of the facility conducted with the Physichal Plant Supervisor (employee #8), the medical gas cylinder storage area was observed to have worn, faded, and deteriorated identification labels. In addition, required signage indicating “No Smoking” and identifying the types of medical gases stored within the area was missing or no longer legible. The medical gas cylinder storage area was not maintained with the required identification and warning signs necessary to promote the safe storage and handling of compressed medical gas cylinders in accordance with NFPA 99. The findings were verified by the Physical Plant Supervisor at the time of the observation.”