Doctors’ Center Hospital San Juan

“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: 51782 Based on the review of personnel credential files (CF) and State Law License regulations requirements, five Nurse credential file (NCF), three Certified Registered Nurse Anesthetist (CRNACF) and three Operation Room Technician (ORTCF), it was determined that the facility failed to updated personnel credential files related to professional staff comply with the Cardiopulmonary Resuscitation (CPR) and Influenza Vaccine, 5 out of 11 credential file (C.F) (N.C.F. #4, and #5), (O.R.T.C.F #1) and (C.R.N.A.C.F #1 and #2). Findings include: 1.During review of three personnel operating room technicians’ credential files with the Human Resources Manager (employee #38) performed on 08/28/2025 at 9:01 AM provided evidence of the following: a) One out of three credential files failed to show updated evidence of in person Cardiopulmonary Resuscitation (CPR) accredited by the American Heart Association, the evidence provided was online CPR: (ORTCF #1) provides evidence of an online CPR expiration on 03/2026. 2. During review of five personnel nurse credential files with the Human Resources Manager (employee #38) performed on 08/28/2025 at 9:30 AM provided evidence of the following: a)Two out of five credential files failed to show updated evidence of in person Cardiopulmonary Resuscitation (CPR) accredited by the American Heart Association, the evidence provided was online CPR: -(NCF #4) provides evidence of an online CPR expiration on 03/2026. -(NCF #5) provides evidence of an online CPR expiration on 07/2027. 3. During review of three personnel Certified Registered Nurse Anesthetist credential files with the Human Resources Manager (employee #38) performed on 08/28/2025 at 9:51 AM provided evidence of the following: a) Two out of three credential files failed to show updated evidence of Influenza Vaccine or the Exoneration form for Influenza Vaccine (C.R.N.A.C.F #1) and (C.R.N.A.C.F #2). b) One out of three credential files failed to show updated evidence of the CPR, the certification expired on 07/2025 (C.R.N.A.C.F #2). The facility failed to ensure that professional staff comply with requirements.”

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 51782 Based on the review of documents and the interview with the Therapy Department Supervisor (employee #9) and the Human Resources Manager (employee #38), it was determined that the facility failed to ensure the credentials files (CF) for contracted services were updated for 3 out of 5 respiratory therapy credentials. (CF#4, CF#9 and CF#10) Findings include: 1. The facility has respiratory therapy under contracted services. During review of five personnel credential files with the Human Resources Manager (employee #38) on 08/27/2025 at 1:30 PM provided evidence of the following: a. Three out of five credential files failed to show updated evidence of Influenza Vaccine or the Exoneration form for Influenza Vaccine (C.F #4, C.F #9 and C.F #10). The facility failed to ensure that contracted professional staff comply with requirements.”

“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: 51782 Based on eight (8) 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 7 out of 8 actives and closed records reviewed (RR. #30, #31, 39, # 59, # 60, # 69 and # 71). Findings include: Facility policy provided by admissions manager (employee #16) on 08/27/2025 at 12:06 PM was reviewed. “Política de Manejo de Admisiones de Pacientes Medicare Tradicional y Medicare Advantage” was revised on 02/2024, stated that the patient is informed about their appeal rights if they disagree with the discharge at the time of discharge. They are informed and given the “Important Message from Medicare” form about their rights, which outlines the procedure to follow: -Contacting the hospital official (Discharge Planner). 1. RR #30 is a 68-year-old female Medicare beneficiary who was admitted on 08/21/2025 with a diagnosis of Acute Pneumonia, Hypoxemia, Bronchospasm. The record was reviewed on 08/27/2025 at 10:42 AM. The clinical record did not evidence that a copy of Medicare Important Message was provided upon admission. 2. RR #31 is a 71-year-old female Medicare beneficiary who was admitted on 08/20/2025 with a diagnosis of Clinical Pneumonia with Acute Bronchitis and Bronchospasm. The record was reviewed on 08/27/2025 at 9:52 AM. The clinical record did not evidence that a copy of Medicare Important Message was provided upon admission. 3. RR #39 is a 76-year-old female Medicare beneficiary who was admitted on 07/18/2025 with a diagnosis of Clinical Bronchopneumonia (BKP), Congestive Heart Failure (CHF), Hypotension. The record was reviewed on 08/27/2025 at 9:56 AM. The clinical record did not evidence that a copy of Medicare Important Message was provided upon admission. During an interview on 08/27/2025 at 11:47 AM with the admissions manager (Employee #16), she stated that the Important Medicare Message document should be given to beneficiaries during the admissions process and upon discharge. She stated that once the patient signs the document, it is placed in the medical record; that if it was not in the medical record, the admissions officer would not take the patient’s signature. 51629 4.The policy named: “Livanta Mensaje Importante de Medicare” (03/2024 revision) was discussed and reviewed with the Discharge Planning Coordinator (employee # 18) on 08/27/2025 at 11:10 AM. The facility policy states that a discharge planning assessment must be performed during the initial assessment, but it does not indicate the delivery of the important Medicare message at least 2 days before discharge. 5.RR # 59 is a 86-year-old female Medicare beneficiary who was admitted on 03/18/2025 with a diagnosis of Right Hip Fracture. The patient was transferred on 03/15/2025 to a rehabilitation center. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to the transfer. 6.RR # 60 is a 77-year-old male Medicare beneficiary who was admitted on 03/22/2025 with a diagnosis of Congestive Heart Failure and Pulmonary Edema. The patient was discharged home on 04/02/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to the discharge. 7.RR # 69 is a 86-year-old female Medicare beneficiary who was admitted on 11/03/2024 with a diagnosis of Acute Colitis with Mesenteritis. The patient was transferred on 02/07/2025 to a nursing home. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to the transfer. 8.RR # 71 is a 86-year-old female Medicare beneficiary who was admitted on 08/12/2025 with a diagnosis of Sepsis, Hypovolemia and Hypernatremia. The patient was transferred to a nursing home on 08/26/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to the discharge.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 51782 Based on review of restraint policy and procedure (P&Ps), interviews with the Intensive Care Unit (ICU) supervisor (employee #14) and Telemetry Supervisor (employee #15), it was determined that facility failed to ensure that patients be free from restraint of any form, and be imposed to ensure the immediate physical safety of the patient, staff member, and be discontinued at the earliest possible, for 2 out of 2 patient in restraint. (RR #37 and #38). Findings include: Facility policy provided by Institutional Program Supervisor (employee #20), on 08/27/2025 at 1:02 PM was reviewed. The policy was reviewed in August 2017, “Norma y Protocolo Sobre Restricción de Paciente”. The policy states on page 2 in section 8 that the medical order must include the reason for the restraint, the body parts to be restrained, and the length of the restraint. 1.R.R. #37 is an 60-year-old female admitted to the facility on 08/16/2025 with a diagnosis of End Stage Renal Disease (ESRD). During the record review performed on 08/27/2025 at 8:50 AM it was found that on 08/26/2025 at 9:23 AM the physician ordered restraint due to chemical sedation off. However, the order does not detail the areas to be restricted and the time it should be restricted. 2. R.R. #38 is an 58-year-old female admitted to the facility on 08/10/2025 with a diagnosis of Respiratory Failure on Mechanical Ventilator (MV), Pneumonia, Hepatic Encephalopathy. During the record review performed on 08/27/2025 at 9:25 AM it was found that on 08/27/2025 at 7:59 AM the physician ordered restraint. However, the order does not detail reason for the restriction, the areas to be restricted and the time it should be restricted.”

“PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT CFR(s): 482.13(g)(1) & (3)(i) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (1) With the exception of deaths described under paragraph (g)(2) of this section, the hospital must report the following information to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint used on the patient during this time.”Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.... (3) The staff must document in the patient’s medical record the date and time the death was: (i) Reported to CMS for deaths described in paragraph (g)(1) of this section; or .... This Standard is not met as evidenced by: 51782 Based on review of restraint policy and interviews, it was determined that the facility failed to ensure that hospitals must report deaths to CMS associated with the use of seclusion or restraint. Findings include: 1. During the review of the standard and protocol on patient restraint facility policy, performed on 08/27/2025 at 1:02 PM, there was no mention that deaths associated with patients in restraints should be reported to CMS accordingly with State Operation Manual Appendix A (Rev. 220; Issued:04/19/24) TAG A 0213 s §482.13(g)(1) & (3)(i) the hospital must report the following information to CMS by telephone, facsimile, or electronically. In an interview with the Institutional Program Supervisor (employee #20) performed on 08/28/2025 at 8:20 AM, she stated that she did not have a policy and procedure for reporting deaths due to restrictions and that was not aware that these cases of restraint death must be reported to CMS.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 15884 Based on review of quality assurance activities with the Institutional Program Director (employee #20), it was identified that the facility failed to include contracted services in the Quality Assessment and Performance Improvement (QAPI) program. Findings include: 1. During the review of the facility’s hospital-wide quality assurance activities master plan natural year 2025 with the Institutional Program Director (employee #20) on 08/27/2025 at 1:50 pm it was identified that contracted services were included as part of services to be submitted as quality indicators data to evaluate the performance of the services. However, there are some contracted services that are not submitting data collected based on indicators to track performance of the service. 2. Biomedical services, acute dialysis, laundry, ambulances, regular and biohazard waste services are contracted services that are not submitting data collected based on indicators to track performance of the service. During an interview on 08/27/2025 at 2:05 pm Institutional Program Director (employee #20) stated that biomedical services, acute dialysis, laundry, ambulances, regular and biohazard waste does not submit QAPI any indicators or data to be used to ensure the appropriateness of services that they provide. 3.Hospital’s governing body failed to ensure that the program reflects the complexity of the hospital’s organization and services; it involves all hospital departments and services. 47632 4. During an interview with the supervisor of operating room (employee #1) on 08/28/2025 at 9:54 AM, stated she does not have infection control indicators. She has been carrying out those ordered by the quality department. It was found that the anesthesia area lacks quality indicators, with only three available. 5. During an interview with the supervisor of anesthesia (employee #6) on 08/28/2025 at 11:38 AM, she stated she does not have infection control indicators. She has been carrying out those ordered by the quality department. The infection control staff member (employee #25) was interviewed on 08/27/2025 at 8:15 AM, she stated that infection control indicators had not been integrated into the operating room department.”

“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: 51629 Based on interviews with the Director of Nursing (DON) (employee # 17) and document reviewed performed on 08/28/2025 at 11:00 AM, it was identified that the facility failed to comply with the provisions of the state law regulating the practice of nursing in PR (Law # 254 of December 31, 2015). Findings include: 1. During an interview with the Director of Nursing (employee # 17) on 08/28/2025 at 11:00 AM, it was informed that the facility employs nursing students to act as “clinical facilitators”. The actual staff in this category are three employes. 2.Upon review of the document: “Job Description, Clinical Facilitators position” (2024 revision), it showed the following duties and responsibilities whose execution are only authorized by the state law to various categories of nursing: Registered Nurse (RN) and Licensed Practical Nurse (LPN): a. Assistance in hygiene, mobility, hydration, elimination and nutrition. b. Taking and documentation of vital signs, intake and output. c. Patient education d. Oral, skin, nail and hair care e. Position changes f. Assistance to the skin care specialists through the placement of preventive dressings The document: “Job Description, Clinical Facilitators position” (2024 revision), was discussed with director of nursing (DON). She stated that “Clinical Facilitators” are certified in their competencies before being authorized to perform. Nevertheless, she was told that the state law mentioned assigns such tasks only to Registered Nurses (Article 2, Definitions, (3)) and Licensed Practical Nurses (Article 2, Definitions, (g)) who must have a nursing license prior to practicing the profession, as follows: a. Licensed Practical Nurse (Article 2, Definitions, (g) # 1) - Performs basic nursing procedures and techniques related to hygiene, comfort, feeding, elimination, ambulation, rest, and other needs of the patient/client. b. Registered Nurses (Article 2, Definitions, (3)) - A person who holds a bachelor’s degree in nursing from a higher education institution authorized and recognized by the Board and Council of Education of Puerto Rico and who holds a license granted by the Board authorizing him or her to practice said role in Puerto Rico. Provides direct nursing care to individuals, families, and communities in a variety of health settings. 3. The facility failed to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 20423 Based on seventy-eight (78) record review (RR), it was determined that facility failed to ensure that the patient medical record entries are complete, authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures related to lack of Physician History and physical evaluation, lack Nurse history or initial evaluation, lack Nurse progress note, incomplete restraint order, lack of nurses assessment every 2 hour when patient restrain, lack of countersign the physician telephonic order, Important Medicare Message not provided to the Medicare patient, clinical records did not contain information related to: clinical area, mechanical ventilator (yes or no), name of nurse and license number of who referred the case and hour of notification to LifeLink for 30 out of 78 records reviewed (RR #7, 9, 10, 11, 14, 15, 16, 17, 18, 19, 21, 22, 23, 24, 25, 27, 28, 29, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, and 52). Findings include: During the review of twelve close records for the condition of participation of Medical Record Services 482.24 on 08/26/2025 through 08/28/2025 from 8:30 am till 3:30 pm it was found the following: 1. R.R. #41 is a 65-year-old male admitted to the facility on 06/26/2025 with a diagnosis of Cutaneous Abscess of Back, Cellulitis Left Upper Limb and discharge home on 06/30/2025. During the record review performed on 08/26/2025 at 2:30 pm the following was found: a.The record lack of the Important Medicare Message provided 48 hours (hrs) before the discharge. b. The Record lack of the nurse’s progress note of 06/27/2025 3-11 shift , 06/28/2025 7-3 shift, 06/29/2025 3-11 shift and 06/30/2025 7-3 shift. 2. R.R. #42 is a 76-year-old female admitted to the facility on 06/27/2025 with a diagnosis of Spinal Stenosis and discharge home on 06/29/2025. During the record reviewed performed on 08/26/2025 at 3:00 pm the following was found: a. The record lack of the Important Medicare Message provided 48 hrs., before the discharge. 3. R.R. #43 is a 72-year-old male admitted to the facility on 05/10/2025 with a diagnosis of Left Sided Obstructive Uropathy and discharge home on 05/14/2025. During the record review performed on 08/26/2025 at 3:30 pm the following was found: a. The record lack of the Important Medicare Message provided 48 hrs., before the discharge. 4. R.R. #44 is a 69-year-old male admitted to the facility on 05/07/2025 with a diagnosis of Lower Gastrointestinal Bleeding, Acute Diverticulitis and discharge home on 05/09/2025. During the record review performed on 08/27/2025 at 8:30 am the following was found: a. The record lack of the Important Medicare Message provided 48 hrs., before the discharge. b. The Record lack of the nurse’s progress note of 05/08/2025 at 3-11 shift. 5. R.R. #45 is a 74-year-old male admitted to the facility on 04/06/2025 with a diagnosis of Stroke Evolution, Altered Mental Status (AMS) and Sudden Disorientation and patient dead on 05/07/2025 at 5:11 pm. During the record review performed on 08/27/2025 at 9:10 am the following was found: a. On 04/06/2025 at 22:40 the physician places an order for soft restraint every 2 hours and renewed on 04/11/2025 at 23:06, on 04/21/2025 at 15:15, on 04/22/2025 at 16:19, on 04/24/2025 at 16:10, 04/29/2025 at 6:00 am, on 04/30/2025 at 15:25, on 05/01/2025 at 13:53, on 05/7/2025 at 15:04. This physicians’ order lack of how much time the is patient going to be restraint, Lack of the reason for restraint, lack the less restrictive measure before restraint, and lack areas to be restraint. b. The Record lack of the nurse’s restraint assessment every 2 hours from 04/6/2025 through 4/8/2025, from 04/11/2025 through 04/15/2025, from 04/19/2025 through 04/20/2025 on 04/25/2025 from 12:45 through 6:00 am, on 04/30/2025 from 1:00 am through 5:43 am, 05/01/2025 from 1:25 am through 7:00 am, on 05/02/2025 from 2:31 am through 7:00 am c. The Record provides evidence on Nurse restraint assessment that patient was restraint without a physician restraint order: - on 04/15/2025 at 12:25 am, at 8:25 am and at 16:00. - on 04/16/2025 at 12:00 am, at 8:00 am and at 16:00. - on 04/17/2025 at 12:00 am, at 8:00 am and at 16:00. - on 04/18/2025 at 12:00 am, at 8:00 am and at 16:00. - on 04/23/2025 at 17:00, at 19:00, at 21:00 and at 23:00. - on 04/24/2025 at 1:00 am, at 2:52 am , 5:00 am, 6:00 am at 7:00 am at 9:00 at 11:00 am, at 13:00 and at 15:00. - on 04/25/2025 at 17:00, at 19:00, at 21:00 and at 23:00. - on 04/26/2025 at 12:57 am, at 2:46 am , 5:00 am, 6:00 am at 7:00 am at 9:00. at 11:00 am, at 13:00, at 15:00, at 17:00, at 19:00, at 21:00 and at 23:00. - on 04/27/2025 at 1:00 am, at 2:39 am , 5:00 am, 6:00 am at 7:00 am at 11:00 am, at 13:15, at 17:00, at 19:00, at 21:00 and at 23:00. - on 04/28/2025 at 12:51 am, at 1:38 am , 5:00 am, 6:00 am at 7:00 am at 9:00 at 11:00 am, at 13:00, at 15:00, at 17:00, at 19:00, and at 21:00. - on 04/29/2025 at 1:00 am, at 1:54 am , 3:45 am, 4:57 am. - on 05/02/2025 at 12:57 am, at 15:00, at 17:00, at 19:00, at 21:00 and at 23:00. - on 05/03/2025 at 1:00 am, at 3:00 am , 5:00 am, 8:00 am 16:00, at 22:54. - on 05/04/2025 at 8:00 am, at 15:21,and at 23:27. - on 05/05/2025 at 8:00 am, and at 16:00. - on 05/06/2025 at 12:00 am, at 8:00 am and at 16:00. - on 05/07/2025 at 12:00 am, and at 8:00 am. d. The Record lack of the nurse’s progress note on 04/07/2025 11-7, 7-3 and 3-11 shift on 04/08/2025 11-7, 7-3 and 3-11 shift, on 04/09/2025 11-7, 7-3 and 3-11 shift, on 04/10/2025 11-7, and 7-3 shift, on 04/11/2025 7-3, and 3-11 shift, on 04/12/2025 7-3 shift, on 04/14/2025 7-3, and 3-11 shift, on 04/15/2025 7-3, and 3-11 shift, on on 04/16/2025 3-11 shift. e. No evidence was found related to restraint consent. 6. R.R. #46 is a 77-year-old male admitted to the facility on 04/09/2025 with a diagnosis of Right/Left Total Knee Arthroplasty and discharge home on 04/11/2025. During the record review performed on 08/27/2025 at 1:00 pm the following was found: a. The record lack of the Important Medicare Message provided 48 hrs., before the discharge. 7. R.R. #47 is a 63-year-old male admitted to the facility on 05/16/2025 with a diagnosis of Chronic Ulcer Left Heel and discharge home on 05/20/2025. During the record review performed on 08/27/2025 at 1:30 pm the following was found: a. The Nurse Initial Assessment was performed 3 days after the admission on 05/19/2025. b. The medical record lack of the nurse’s progress note on 05/18/2025 7-3 shift, on 05/19/2025 7-3 shift, on 05/20/2025 11-7 shift. 8. R.R. #48 is a 79-year-old female admitted to the facility on 03/16/2025 with a diagnosis of Right Femur Fracture and discharge on 03/25/2025. During the record review performed on 08/28/2025 at 9:30 am the following was found: a. The record lack of the Important Medicare Message provided 48 hrs., before the discharge. b. The record lack of the nurse’s progress notes on 03/19/2025 3-11 shift, on 03/20/2025 11-7, and 7-3 shift, and on 03/24/2025 11-7 shift. 9. R.R. #49 is a 77-year-old female admitted to the facility on 03/13/2025 with a diagnosis of Hypertensive Crisis and Bacteremia and discharge on 03/18/2025. During the record review performed on 08/28/2025 at 10:30 am the following was found: a. The record lack of the Important Medicare Message provided 48 hrs., before the discharge. b. The Record lack of the nurse’s progress note on 03/16/2025 at 3-11 shift, on 03/17/2025 at 3-11 shift, on 03/18/2025 at 7-3 shift, 03/19/2025 7-3 and 3-11 shift on 03/20/2025 3-11 shift, and on 03/22/2025 7-3 shift. 10. R.R. #50 is a 68-year-old male admitted to the facility on 02/01/2025 with a diagnosis of Left Leg Osteomyelitis and discharge on 02/24/2025. During the record review performed on 08/28/2025 at 11:45 am the following was found: a. The record lack of the Important Medicare Message provided 48 hrs., before the discharge. b. The Record lack of the nurses progress note on 02/02/2025 at 11-7, and 7-3 shift, on 02/03/2025 at 7-3 and 3-11 shift, 02/04/2025 at 7-3 and 3-11 shift, on 02/06/2025 at 11-7, 7-3 and 3-11 shift, on 02/07/2025 at 7-3 shift, on 02/08/2025 at 11-7 and 7-3 shift, 02/09/2025 at 11-7 and 3-11 shift, on 02/10/2025 at 3-11 shift, on 02/11/2025 at 7-3 shift, on 02/13/2025 at 3-11 shift on 02/19/2025 at 11-7 shift and on 02/23/2025 3-11 shift. 11. R.R. #51 is a 71-year-old male admitted to the facility on 02/05/2025 with a diagnosis of Left Leg Cellulitis and discharge on 02/12/2025. During the record review performed on 08/28/2025 at 1:00 pm the following was found: a. The record lack of the Important Medicare Message provided 48 hrs., before the discharge. b. The Record lack of the nurse’s progress note on 02/11/2025 11-7 shift, and on 02/12/2025 11-7 shift. c. The record lack of the Nurse Initial Evaluation. d. The record lack of Anticipate Directive Orientation. e. The transfusion Consent was without patient and physician sign. 12. R.R. #52 is a 69-year-old male admitted to the facility on 01/20/2025 with a diagnosis of Dysphagia, Myocardial Infarct and discharge on 01/27/2025. During the record review performed on 08/28/2025 at 1:00 pm the following was found: a. The record lack of the Important Medicare Message provided 48 hrs., before the discharge. b. The record lack of Anticipate Directive Orientation was not sign c. The Record lack of the nurse’s progress note on 01/26/2025 11-7 and 7-3 shift. 47632 13. R.R #21 is a 30 year-old female admitted to the facility on 01/20/2025 with a diagnosis of L-5-S1 laminotomy discectomy with endoscopy spinal (outpatient). During the record review performed on 08/26/2025 2:42 PM, the following was found: a. It was noted that the staff did not make the call within 24 to 48 hours after discharge. The call was made on February 6, 2025 at 10:20 AM. 14. R.R #22 is a 18 year-old female admitted to the facility on 02/10/2025 with a diagnosis of Posterior spinal fusion and instrumentation T-4 L-4. During the record review performed on 08/27/2025 9:08 AM, the following was found: a. The intraoperative anesthesia sheet showed that the anesthesiologist’s signatures were missing on the second sheet. 15. R.R #23 is a 61 year-old male admitted to the facility on 01/28/2025 with a diagnosis of Pulse generator replacement and lead revision (outpatient). During the record review performed on 08/26/2025 3:08 PM, the following was found: a. It was noted that the staff did not make the call within 24 to 48 hours after discharge. The call was made on February 6, 2025 at 10:08 AM. 16. R.R #24 is a 47 year-old male admitted to the facility on 03/05/2025 with a diagnosis of Hemorrhoidectomy, proctoplasty (outpatient). During the record review performed on 08/26/2025 9:20 AM, the following was found: a. It was noted that the staff did not make the call within 24 to 48 hours after discharge. b. The absence of the patient’s vital signs is noted in the history and physical examination sheet. 17. R.R #25 is a 29 year-old male admitted to the facility on 03/26/2025 with a diagnosis of Excision of anal warts (outpatient). During the record review performed on 08/27/2025 9:31 AM, the following was found: a. It was noted that the staff did not make the call within 24 to 48 hours after discharge. The call was made on March 4, 2025 at 11:08 AM. b. The absence of the patient’s vital signs is noted in the history and physical examination sheet. 18.R.R #27 is a 65 year-old female admitted to the facility on 05/14/2025 with a diagnosis of Right knee arthroplasty (outpatient). During the record review performed on 08/27/2025 9:54 AM, the following was found: a. It was noted that the staff did not make the call within 24 to 48 hours after discharge. The call was made on May 27, 2025 at 1:55 PM. b. It was noted that the physical history sheet was blank. c. It was noted that the medical consent form for the operation did not have a date or time. 19. R.R #28 is a 76 year-old male admitted to the facility on 02/10/2025 with a diagnosis of Anterior spinal fusion L-2 L-5 . During the record review performed on 08/27/2025 8:50 AM, the following was found: a. The CBC, BMP, urinalysis, and Pt/Ptt tests were not found. b. It was noted on the medical history and physical examination form that the date the physician signed it was missing. c. The medical history and review of the physical examination form prior to surgery or procedure showed that it was blank and lacked the physician’s signature, license number, date, and time. d. The intraoperative anesthesia sheet showed that the signatures of the nurse anesthetist and anesthesiologist were missing on the second sheet. 20. R.R #29 is a 72 year-old female admitted to the facility on 06/24/2025 with a diagnosis of Left completion thyroidectomy with RLN monitoring (outpatient). During the record review performed on 08/27/2025 10:04 AM, the following was found: a. It was noted that the medical history and physical examination form was missing the date. b. It was found that staff did not make the call within 24 to 48 hours after discharge. 17959 21. During the review of (19) nineteen records of Organ, Tissue and Eye Procurement (OPO) , Policy and Procedures Manual with the Institutional Program and OPO designated nurse, it was found that the clinical records did not contain information related to: clinical area, mechanical ventilator (yes or no), name of nurse and license number of who referred the case and hour of notification to LifeLink. a. R.R. #7 is an 80-year-old male admitted on 01/26/2025 at Medicine ward with diagnosis of UTI and died on 03/04/2025 at 4:15 PM. Referred to Life Link of Puerto Rico does not indicate if the patient was on mechanical ventilation and the license of the nursing professional who notifies the case is missing. b. R.R. #9 is a 67-year-old male admitted on 03/24/2025 with diagnosis of Respiratory failure and died on 03/24/2025 at 10:59 PM. Referred to LifeLink of Puerto Rico the form did not indicate clinical area where the patient was located. c. R.R. #10 is a 90-year-old female admitted on 03/25/2025 with diagnosis of C-UTI, DCHF and Actic Acidosis and died on 03/28/2025. Referred to LifeLink of Puerto Rico the form did not indicate license number of the nurse who referred the case to Lifelink, the hour of death and the hour when the nurse notifies Lifelink. d. R.R. #11 is a 90-year-old male admitted on 03/18/2025 with diagnosis of Hydroureteronephrosis and died on 04/04/2025 at 4:49 AM. Referred to LifeLink of Puerto Rico on 04/04/2025 at 5:05 AM, the form did not indicate the clinical area and the license number of the nurse who referred the case to LifeLink. e. R.R. #14 is a 94-year-old female admitted on 05/28/2025 with diagnosis of Decompensated Congestive Heart Failure and Pulmonary Edema and died on 05/31/2025 at 11:22 PM. Referred to LifeLink of Puerto Rico on 05/31/2025 at 11:33 PM the form did not indicate the name and the license number of the nurse who referred the case to LifeLink. f. R.R. #15 is a 76-year-old female admitted on 05/11/2025 with diagnosis of COPD and died on 06/02/2025 at 2:42 AM. Referred to LifeLink of Puerto Rico on 06/02/2025 at 2:50 AM, the form did not indicate license number of the nurse who referred the case to LifeLink. g. R.R. #16 is an 87-year-old male admitted on 06/18/2025 with diagnosis of Acute Kidney Injury with Hyperkalemia and died on 07/04/2025 at 12:32 PM. Referred to LifeLink de Puerto Rico on 07/04/2025 at 12:36 however the hour of notification indicates AM and PM. The form did not indicate license number of the nurse who referred the case to Lifelink. h. R.R. #17 is an 89-year-old female admitted on 05/28/2025 with diagnosis of Peg Malfunction with Purulent Secretion Left and died on 07/04/2025 at 7:30 PM. Referred to Life Link de Puerto Rico on 07/04/2025 at 7:43 PM. The form did not indicate license number of the nurse who referred the case to LifeLink. i. R.R. #18 is a 61-year-old female admitted on 07/06/2025 with diagnosis of Respiratory Distress and died on 07/06/2025 at 7:02 AM. Referred to LifeLink of Puerto Rico on 07/06/2025 at 7:10 AM. The form did not indicate license number of the nurse who referred the case to LifeLink. j. R.R. #19 is an 89-year-old female admitted on 07/03/2025 with diagnosis of Pneumonia, Right Shoulder Fracture and Right Femoral Fracture and died on 07/12/2025 at 2:20 AM. Referred to LifeLink of Puerto Rico on 07/12/2025 at 2:45 AM. The form did not indicate license number of the nurse who referred the case to Lifelink.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 47632 Based on observations made in the anesthesia storage room on 08/28/2025 at 12:34 PM, it was determined that the facility failed to ensure that anesthesia personnel medications were stored in a secure and properly locked area. Findings include: 1. During the inspection of the anesthesia storage area with the supervisor (employee #6), it was observed that some medications belonging to the anesthesia staff were accessible to any member of staff. 2. The storage area is not lockable, and any member of staff can easily enter and exit.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 15884 Based on dining observations, review of policies procedures and facility staff interview performed on 08/26/2025 through 08/28/2025 to from 8:30 am through 4:30 pm, it was determined that the facility failed to ensure that each patient receives, and the facility provides food and drinks that are palatable, at a safe and appetizing temperature. This deficiency affects 78 out of 83 cases admitted receiving services. Findings include: During the lunch tray line observation process on 08/26/2025 from 11:00 am through 1:00 pm the following findings were identified: 1.Kitchen supervisor (employee #36 ) was observed measuring the temperature of the food before proceeding to serve the line. The temperature of the fruit cocktail was 50-degree Fahrenheit and milk was 51 degree Fahrenheit. The Kitchen supervisor (employee #36 ) stated on an interview on 08/26/2025 from 11:10 am that cold items to be provided to patient must have a temperature of 41 degree Fahrenheit or less. 2. Fruit cocktail and milk was served without taking any provision to achieve the required temperature. 3. Facility food temperature requirements policy was reviewed with administrative dietitian (employee #37 ) on 08/26/2025 at 11:55 am. The policy establishes that cold food items must have a temperature of 41-degree Fahrenheit or less. 4. During observations on 08/26/2025 at 12:00 pm it was observed that the refrigerator used to store cold items to be served subsequently in the tray line had the door rubber broken. This prevents the door seal and the cold escapes from the refrigerator. The surveyor asked the administrative dietitian (employee #37 ) on 08/26/2025 at 12:05 pm if the defect ( broken rubber ) had been reported to the maintenance personnel, since approximately more than three months. 5. The facility failed to ensure that cold food and drink provided to residents maintain an appetizing temperature.”

“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 observations, and facility staff interview performed on 08/26/2025 through 08/28/2025 to from 8:30 am through 4:30 pm, it was determined that the facility failed to maintain 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. During observation of the physichal enviroment throught all three days, ceiling tiles were observed with water stains in the following areas: a) Surgery Department recovery area bathroom b) Surgery Department recovery in front of cubicle 4 c) Surgery Department Sterile equipment warehouse d) Emergency Ward “cuarto de suero e) Laboratory Department near window f) Physichal Therapy Department 2. During observation of the physichal enviroment on the Surgery Department it was noticed that in the operating rooms Monolithic paneling had perforations due to screws than later were taken off. 3.During observation of the physichal enviroment on the Surgery Department it was noticed that in the operating rooms Monolithic flooring had broken areas in Surgery Room C.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47384 Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility’s Plant Manager and Safety Officer, 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 from 8/26/2025 through 8/29/2025 from 8:00 am till 3:30 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form (K211, K222, K223, K293, K321, K325, K342, K343, K353, K355, K363, K904, K918 and Tag 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: 15884 Based on observations, and facility staff interview performed on 08/26/2025 through 08/28/2025 to from 8:30 am through 4:30 pm, it was determined that the facility failed to ensure that facility and equipment is maintained to ensure an acceptable level of safety and quality. Findings include: During the radiology department survey procedures with X Rays department supervisor ( employee # 23 ) on 08/27/2025 from 10:00 am through 12:00 pm the following findings were identified: 1. Radiology department defibrillator did not have the inspection label of the biomedical services. 2. The surveyor asked the X Rays department supervisor ( employee # 23 ) on 08/27/2025 from 11:00 am if the equipment had been inspected by the biomedical services personnel. The X Rays department supervisor ( employee # 23 ) stated in an interview on 08/27/2025 from 11:10 am that the equipment had been inspected. However, he does not specify the date when the inspection was performed. 3.The facility administrator (employee # 19) was interviewed on 08/27/2025 at 2:00 pm and was asked for the inventory, certification or report of the biomedical services equipment maintenance. She stated that they had a contract with a company who perform the maintenance and certification of the equipment. 4. The facility administrator (employee # 19) was asked on 08/27/2025 at 2:20 pm who is the person at the facility who is in charge to verify that the biomedical services company review and perform maintenance of the required equipment. The administrator (employee # 19) stated in the interview on 08/27/2025 at 2:25 pm that no one was assigned to be in charge of ensure that biomedical services equipment maintenance company carry out the work for which they were contracted. 47632 5. During observation on 08/26/2025 at 8:53 AM, in endoscopy rooms 1 and 2, in preparation areas A, B, C, D, E, and F, and in recovery rooms 1, 2, 3, 4, and 5, the stretchers did not have a nurse call system accessible to the patient. 6. On 08/26/2025 at 2:02 PM, the crash cart located in the hallway was observed to have a cardiac monitor defibrillate with an inspection date of 12/2023 and a suction machine that did not have a preventive maintenance seal. 7. On 08/26/2025 at 10:30 AM, a hole was observed in the wall in the instrumentation area. 8. On 08/27/2025 at 10:30 AM, on the fifth floor, five out of five cardiac monitors without preventive maintenance and two warming patients without preventive maintenance were observed in the recovery area. 9. On 08/27/2025 at 2:30 PM, it was observed that the autoclave had no door and was being used to process material. 10. On 08/28/2025 at 10:13 AM, it was noted that the defibrillator in the crash cart in the recovery room on the fifth floor had not undergone its annual maintenance. 11. On 08/28/2025 at 10:28 AM, it was noted that the defibrillator in the crash cart in the operating room on the fifth floor had not undergone its annual maintenance. 12 On08/28/2025 at 11:30 AM, nitrogen tank was observed in the induction area on the fifth floor, located directly on the floor without a base. During an interview conducted on 08/27/2025 at 3:11 PM, the operations room supervisor (employee # 1), she stated that she had communicated with the physical plant staff on several occasions. She then provided all the notifications made to the physical plant staff during 2025 so that the necessary measures could be taken. 51629 13. Pediatric ward - a scale with a preventive maintenance seal dated on august 2019. 14.Pediatric ward - crash cart without defibrillator. The director of nursing (employee # 17) stated that the purchase of that equipment was requested and that the quote was already available. 15. Surgery ward, third floor - crash cart with defibrillator. The latter did not have an inspection seal. The director of nursing (employee # 17) stated that the equipment was recently acquired. The facility failed to ensure adequate maintenance of facility’s supplies and equipment to ensure an acceptable level of safety and quality.”

“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: 51782 Based on the observational tour in the Respiratory Therapy Department with the Therapy Respiratory Supervisor (employee #9) on 08/26/2025 through 8/28/2025 from 8:30 AM to 4:00 PM and interview, it was determined that the facility failed to provide standards for infection control related to preventing and controlling the transmission of infections within the hospital. Findings include: 1. During the round made with the Therapy Respiratory Supervisor (employee #9) in the respiratory therapy department area on 08/26/2024 at 9:45 AM, the following was observed: a) On 08/26/2025 at 10:03 AM, six peep valve expired on 08/13/2023 and three expired on 01/11/2024 were observed on the medical-surgical supplies area of the respiratory therapy department. b) On 08/26/2025 at 10:05 AM, three tracheostomy care kits expired on 04/2025 were observed on the medical-surgical supplies area of the respiratory therapy department. c) On 08/26/2025 at 10:15 AM, two Endotracheal Tube Holder (ET TAPE) expired on 11/2024 were observed on the medical-surgical supplies area of the respiratory therapy department. d) On 08/26/2025 at 10:20 AM, fifty-four Endotracheal Tube Holder (ET TAPE) expired on 01/2025 were observed on the medical-surgical supplies area of the respiratory therapy department. 47632 2. During the procedures evaluated on 08/26/2025 from 9:00 AM to 11:00 AM, the following was observed: a. R.R.# 79 is a 63-year-old male admitted to the facility on 08/26/2025 with a diagnosis of Proslaminectomy in room E. The observation of the procedure, accompanied by the supervisor (employee #1) the following was found: The circulating nurse (employee #3) had three opportunities to wash her hands with soap and water or hand sanitizer before putting on gloves. The nurse anesthetist (employee #2) had three opportunities to wash her hands with soap and water or hand sanitizer before putting on gloves. The nursing assistant (employee #4) was observed handling the patient and entering and leaving the room with the same gloves on. He had two opportunities to change gloves and wash his hands. b. R.R.#80 is a 55-years-old female admitted to the facility on 08/26/2025 with a diagnosis of Cancer of Thyroid in room D. During observation of the procedure, accompanied by the supervisor (employee #1), during the procedure, the following was observed: - A procedure tray was observed placed in the regular trash can. - A surgical drape was observed placed on the IV stand. 3. During observations made in the treatment car, the following were found: - Three sterile gloves, size 6.5, were found with expiration dates of 10/20/2023, 07/10/2023, and 07/28/2025. - Sterile gloves, size 7.0, expired 12/16/2024, were found. - Three blue tubes expired on 06/30/2025 were found. 4. During observations made in the autoclave room on the fifth floor, the following was observed: During an interview on 08/28/2025 at 10:30 AM, with the operating room supervisor, she stated that the autoclave had not been working for approximately two months. a. A temperature of 90 degrees Fahrenheit was observed. The temperature and humidity log were reviewed, and it was found that since June, the parameters had not been maintained within the normal range and no corrective action had been taken in writing. 5. During observations made in the room temperature records, the following was noted: According to the operating room unit temperature and humidity log, the following conditions must be maintained: The appropriate temperature range is 20 degree° Celsius to 21°C (68°F to 70°F). The appropriate humidity range is 30% to 60%. a.In Room B, in July and August 2025, the temperature and humidity were not recorded daily. In May, June, and August 2025, temperature fluctuations of up to 67°C below the appropriate level occurred, and staff did not take corrective action. b. In room D, in March, July, and August 2025, the temperature and humidity were not recorded daily. In March, June, July, and August 2025, temperature fluctuations of up to 53°C below the appropriate level occurred, and staff did not take corrective action. c. In room E, in August 2025, the temperature and humidity were not recorded daily. In March, July, and August 2025, temperature fluctuations of up to 58°C below the appropriate level occurred, and staff did not take corrective action. d. In Room C, in August 2025, temperature and humidity were not recorded daily. In February, March, July, and August 2025, temperature fluctuations of up to 52°C were below the appropriate level and humidity fluctuations of 69% above the appropriate level occurred, but staff did not take corrective action. e. Tray storage: In August 2025, temperature and humidity were not recorded daily. In February, March, July, and August 2025, temperature fluctuations of up to 54°C below the appropriate level and humidity fluctuations of 62% above the appropriate level occurred, but staff did not take corrective action. a. In Room B, in July and August 2025, the temperature and humidity were not recorded daily. In May, June, and August 2025, there were temperature fluctuations, but the staff did not take corrective action. b. In room D, in March, July, and August 2025, the temperature and humidity were not recorded daily. In March, June, July, and August 2025, there was an abnormal temperature, but the staff did not take corrective action. c. In room E, in August 2025, the temperature and humidity were not recorded daily. In March, July, and August 2025, there were temperature fluctuations, but the staff did not take corrective action. d. In Room C, in August 2025, temperature and humidity were not recorded daily. In February, March, July, and August 2025, there were changes in temperature and humidity, but staff did not take corrective action. e. Tray storage: In August 2025, temperature and humidity were not recorded daily. In February, March, July, and August 2025, changes in temperature and humidity occurred, but staff did not take corrective action.”

“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 observations made in the operating room unit from August 26, 2025, to August 28, 2025, from 8:00 AM to 3:30 PM, it was determined that the facility failed to ensure a clean, sanitary, and infection-free environment in the operating rooms. Findings include: 1. During observations made in operating rooms B, C, D, and E on the sixth floor and in rooms 1 and 2 on the fifth floor, recovery, holding, endoscopy and preparation area the following were found: a. Stained acoustics and moisture were observed. b. A personal water bottle and containers were found next to the surgical equipment. c. Paint peeling around surgical lamp. d. A surgical tray was found in a trash can. e. Hand sanitizer was found placed in the sharp container. f. The arm supports for the surgical table were found on the floor. g. Bags of electrical cables were found on the floor. h. A hole was observed in the wall in the endoscopy instrumentation area. i. Peeling paint was observed in the endoscopy area. j. Dark stains were found on the surgical sink. k. A worn-out brush was found in the instrumentation area. l. The surgical medical cabinet without doors was observed on the fifth floor, room #2. m. A temperature of 90 degrees Fahrenheit was observed on the fifth floor, in the autoclave room. 2. During the observation carried out in the supervisor’s office, the following was found: a. A coffee maker, cooking oil, a toaster, a microwave, and chocolate. 3. During observations made in the treatment car, the following were found: a. Three sterile gloves, size 6.5, were found with expiration dates of 10/20/2023, 07/10/2023, and 07/28/2025. b. Sterile gloves, size 7.0, expired 12/16/2024, were found. c. Three blue tubes expired on 06/30/2025 were found. 4. During observations made in the room temperature records, the following was noted: According to the operating room unit temperature and humidity log, the following conditions must be maintained: The appropriate temperature range is 20 degree° Celsius C to 21°C (68°Fahrenheit to 70°F). The appropriate humidity range is 30% to 60%. a. In Room B, in July and August 2025, the temperature and humidity were not recorded daily. In May, June, and August 2025, temperature fluctuations of up to 67°C below the appropriate level occurred, and staff did not take corrective action. b. In room D, in March, July, and August 2025, the temperature and humidity were not recorded daily. In March, June, July, and August 2025, temperature fluctuations of up to 53°Celsius below the appropriate level occurred, and staff did not take corrective action. c. In room E, in August 2025, the temperature and humidity were not recorded daily. In March, July, and August 2025, temperature fluctuations of up to 58°C below the appropriate level occurred, and staff did not take corrective action. d. In Room C, in August 2025, temperature and humidity were not recorded daily. In February, March, July, and August 2025, temperature fluctuations of up to 52°C below the appropriate level and humidity fluctuations of 69% above the appropriate level occurred, but staff did not take corrective action. e. Tray storage: In August 2025, temperature and humidity were not recorded daily. In February, March, July, and August 2025, temperature fluctuations of up to 54°C below the appropriate level and humidity fluctuations of 62% above the appropriate level occurred, but staff did not take corrective action. 51629 5. During a round made on 08/26/2025 from 9:00 AM to 12:00 PM in the clinical areas, findings and observation include: a. Room # 206 - IV stand with rust. b. Rooms # 212, # 305 and # 410 - Overfilled sharp containers on the wall. There were patients in those rooms. c. Medicine ward - a dirty linen cart with vital signs machine next to it, almost touching the cart. d. Medicine 4th ward - a dirty linen cart with vital signs machine next to it, almost touching the cart. The facility failed to provide a clean and sanitary environment to avoid sources and transmission of infection. 51829 6. During a review of the pediatric crash cart on August 26, 2025, at 9:14 a.m. at the emergemncy room, expired medical-surgical supplies were identified. Among the supplies identified were: a. Two fenestrated towels with an expiration date of 2021. b. Expired sample tubes: i. Two violet tubes from July 2015. ii. Seven green tubes from July 31, 2025. iii. Nine blue tubes from July 30, 2025. iv. One red tube from March 31, 2025. c. A review of the laryngoscopes showed that 3 out of 5 did not light up. 2. A review conducted on August 26, 2025, at 9:55 a.m. in the patient screening area revealed a moldy IV fluid dispenser stand. 3. A review conducted on August 26, 2025, at 10:37 a.m. in the adult cardiac arrest cart revealed a damaged suction catheter cover; it was not in good condition for use. 4. A review conducted on August 26, 2025, at 11:08 a.m. in the room where IV fluids are stored revealed deteriorated walls, damaged paint, holes in the wall, and a dark stain from leaking contents in the acoustics. 5. An inspection conducted on August 26, 2025, at 11:27 a.m. in the medical-surgical supply warehouse located in the hallway revealed poor dust control, four boxes of intravenous fluids placed on the floor, and inadequate use of space to organize supplies. 6. An inspection conducted on August 26, 2025, at 11:45 a.m. in the office supply warehouse revealed excessively full supplies, materials placed near the ceiling next to the fire control area, and poor dust control and organization. 7. An inspection conducted on August 26, 2025, at 1:24 p.m. in the emergency room’s dirty linen storage areas, one located in the pediatric area and the other in the adult area, revealed stored supplies such as one large and three small oxygen tanks, a vital signs machine being recharged, and no negative pressure. 8. On August 26, 2025, infection control was compromised during the handwashing process due to the following: a. Handwashing did not follow the required steps and did not last the required amount of time (Employees 28 and 29). b. At 8:33 am, the sink was observed to be accumulating water, clogged, and very small, limiting the required time and space for handwashing in the adult treatment area. c. At 9:09 am, the registered nurse (Employee 31) observed the pen faucet contaminating her hands during the handwashing procedure because she had to press it to get the water to come out before rinsing. 9. During the observation conducted on August 27, 2025, during the medication administration procedure, the following was identified: a. At 9:17 a.m., during observation, the registered nurse (Employee #28) was wearing gloves. During the process, she dispensed the medications, cared for the patient, and administered them, without washing her hands at any time. b. At 9:18 a.m., during the medication administration process, the registered nurse (Employee #29) was observed wearing gloves and changing them without washing her hands. She did not use an alcohol swab to clean the medication dispenser bottle, and during the administration, she did not clean the IV connection with alcohol. She also did not inform the patient of the medication to be administered, as is their right. c. At 9:29 am, the registered nurse was observed not washing her hands when beginning the medication dispensing process. She was wearing gloves and during the glove change, she was not washing her hands and did not use an alcohol swab to extract the medication from the bottle and administer the IV push. d. At 9:35 am, the registered nurse (Employee #32) was observed wearing gloves without washing her hands during the glove change. 10. During the visit conducted on August 27, 2025, with the Infection Control Coordinator (Employee #25) and the General Supervisor (Employee #33), they identified the following: a. At 11:18 am, in the morgue, a refrigerator was observed in the walk-in cooler where the bottom part was damaged, and the top part was working. The hospital also has four stretchers, one of which contains a body that has not been placed in a refrigerator because forensic personnel need to see it and demand its removal, which they prefer to leave outside to avoid moving it. There was no evidence of a policy for the management of bodies that will be sent to Forensic Sciences. This was discussed with the administrator (Employee #19), and she was instructed during the exit conference to look up the most recent law reviewed by Forensic Sciences for these cases. The review was conducted on January 13, 2024, and is directed toward the Management and Shipping of Corpses from a Hospital to Forensic Sciences. b. At 11:30 am, the room where all the soiled sheets used in the hospital are stored did not have the required equipment to measure temperature and humidity, and it did not have negative pressure. During this visit observation made accompanied by the manager (Employee #34). c. At 11:40 a.m., clean sheets were found in a container in front of the employee cafeteria, blocking the exit because it was in a hallway that also served as an exit point. The sheets were unmarked and exposed. d. At 11:50 a.m., the area where the compactor was located was visited. It was found to be poorly cleaned and cleaned, damaged, and a potential source 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 made on August 26 and 27, 2025, an interview conducted with the Infection Control Nurse (Employee #25) on August 27, 2025, at 1:00 PM, and a review of infection control-related documents, the facility failed to develop and implement hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to recognized guidelines. Findings include: 1. No efforts were found related to integration with the general staff and departments. 2. No integrated educational plan was found, aimed at non-clinical and clinical staff, and in turn, at newly recruited staff and mandatory annual training, with all the necessary and required training for infection control in the hospital. 3. No evidence of an infection control plan by department, according to the department’s needs. 4. The educational plan does not demonstrate the impacted staff division; it does not cover all the necessary topics; and the educational programs do not provide references to determine their origin and whether they correspond to guidelines from recognized agencies. 5. There is evidence of the implementation of three indicators that have been in place for more than a year, and the decision is to continue with them. 6. There is no evidence of the inclusion of new indicators for departments and disciplines to increase the monitoring of procedures that require evaluation, such as specific operating room indicators such as terminal cleaning, among others.”

“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: 47632 Based on review of the procedures manual dated 08/20/2025, it was determined that the facility failed to ensure that the manual contained policies designed to guarantee the achievement and maintenance of high standards of medical practice and patient care. Findings include: During the review of the operating room standards and procedures manual with the supervisor (employee no. 1) on 08/27/2025 at 9:54 AM, a lack of standards and structure for infection prevention and control was observed. The nursing administration manual had been in effect since January 2007 and was last reviewed in March 2014. The supervisor was evaluating the manual at the time.”

“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: 47632 Based on observations made in the operating room area from August 26, 2025, to August 28, 2025, it was determined that the facility did not ensure that cardiac monitoring equipment, defibrillators, and medical equipment were inspected, tested, and maintained for 16 out of 16 cardiac monitors and 1 out of 5 defibrillators in the operation room. Findings include: 1. During observations made in the operating room unit on the fifth and sixth floors, the following were observed: a. Five cardiac monitors without up-to-date inspections on the fifth floor and five cardiac monitors without up-to-date inspections on the sixth floor. b. Three defibrillators in the crash cart without up-to-date inspections on the fifth floor and two defibrillators without up-to-date inspections on the sixth floor. c. Four cardiac monitors in the anesthesia carts without up-to-date inspections on the fifth floor and two cardiac monitors in the anesthesia carts without up-to-date inspections on the sixth floor.”

“DELIVERY OF ANESTHESIA SERVICES CFR(s): 482.52(b) Anesthesia services must be consistent with needs and resources. Policies on anesthesia procedures must include the delineation of pre-anesthesia and post-anesthesia responsibilities. The policies must ensure that the following are provided for each patient: This Standard is not met as evidenced by: 47632 Based on review of policies and procedures with the head nurse anesthetist (employee #6) on 08/28/2025, it was determined that the center did not ensure that the standards and procedures manual included infection prevention and control measures, indicators, and medical anesthesia equipment. Findings include: 1. During the review of the anesthesia standards and procedures manual with the supervisor (employee # 6) on 08/28/2025 at 11:38 AM, a lack of standards and structure for infection prevention and control was observed, and there are no infection control indicators. 2. During observations made in the operating room on the fifth and sixth floors, the following were found: a. Six out of six monitors on the anesthesia cart were found to have expired equipment maintenance dates of 04/2022.”

“INTEGRATION OF EMERGENCY SERVICES CFR(s): 482.55(a)(2) [If emergency services are provided at the hospital --] (2) The services must be integrated with other departments of the hospital. This Standard is not met as evidenced by: 51829 Based on an interview, review of the medical record, and established policy, the facility failed to ensure the integration of services into patient care in the emergency room. Time is essential in the provision of services and education. Findings includes: 1. It was identified that a patient with social needs was referred to the social work service by the physician who evaluated the case on August 22, 2025, but was not evaluated by social work until August 26, 2025. This happened after the incident was identified. a. RR #57 was observed alone. The supervisor (employee #26) and the coordinator (employee #27) were interviewed about the patient on August 26, 2025, at 2:40 p.m. They indicated that she does not receive visitors and is alone. They were asked whether she had been referred to social work or what the next step was. b. Upon reviewing the record on August 26, 2025, at 2:48 pm, a patient (RR #57) was identified as having been admitted and referred by the doctor to social work on August 22, 2025. She had not been evaluated and had not received any follow-up consultations. c. Once the omission is identified, social work assesses the patient and provides the policy specifying the timeframe for responding to consults from the social work department. The policy, effective in May 2010 and revised in February 2024, specifies that the consult will be responded to within the next 24 hours, if notified. This patient was assessed 5 days after the referral/consultation ordered by the doctor. 2. It was identified that the glucometer cleaning policy changed regarding the product used for cleaning. a. The emergency room nursing staff indicated that it is cleaned with Caviwipe. In an interview on August 26, 2025, at 3:09 pm, the supervisor (employee #26) indicated that it was recently switched to Clorox. b. Caviwipe was observed in the areas, and the cleaning log sheet indicates Caviwipe-germicide. c. The policy was requested by the surveyor, the policy contained in the March 2011 manual, revised on June 21, 2019, entitled “Use and Regulation of the ACCu-Chek Inform II glucometer.” It must be decontaminated with Caviwipe or alcohol between patients. In an interview conducted on August 26, 2025 at 3:21 a.m., the supervisor (Employee # 35) indicated that it had recently changed and on August 27, 2025 at 10:04 a.m., he provided the surveyor the cleaning policy had changed due to a letter from the manufacturer Rocher obtained from the EPA Pesticide Product and Label System database on May 4, 2020, which recommends cleaning with a germicide and offers a list of Clorox wipe-germicidal and all other germicides. d. Based on this circular, employee #35 provided the new policy prepared but dated August 11, 2023, which indicates cleaning with Clorox germicidal wipes. e. No evidence of any training provided to staff on changing cleaning wipes for the glucometer.”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 51829 Based on the credential files (CF) reviewed conducted on August 27, 2025, at 9:30 a.m. at the emergency room, it was determined that the hospital failed to ensure periodic credential reevaluations, evidenced by expired credentials or lack of evidence for 5 out of 5 credentials (CF#1, 2, 3 , 4, and 5 ). Findings include: 1. During the review of the credential files of five nursing professionals, the following was identified: a. It is evident that the nursing professional (CF #1) had received her influenza vaccination on September 22, 2023, which had expired. No exoneration was evident. The criminal background check has expired (January 26, 2023). It is also evident that her evaluation from January to December 2024 was completed on May 2, 2025. b. CF# 2 had the expired flu vaccine from 09/23/2023. There is also no evidence of exoneration. The criminal recordcertificate has expired (06/27/2023). It is also evident that her evaluation from January to December 2024 was completed on 03/14/2025. c. CF# 3 has the expired CPR from 08/2025. There is also no evidence of having the chickenpox vaccine or the criminal record certificate. It is also evident that her evaluation from January to December 2024 was completed on 02/06/2025. d. CF#4 does not demonstrate that she has had the chickenpox vaccine or the criminal reord certificate. It is also evident that her evaluation from January to December 2024 was completed on March 14, 2025. e. CF#5 does not have a criminal record certificate.”

“RESPIRATORY SERVICES CFR(s): 482.57(b)(4) All respiratory care services orders must be documented in the patient’s medical record in accordance with the requirements at §482.24. This Standard is not met as evidenced by: 51782 Based on the review of five medical records and policies/procedures with the respiratory therapist supervisor (employee #9), it was determined that the facility failed to ensure that Respiratory Therapy services order must be documented in the patient’s medical record in accordance with the requirements for 4 out of 5 records reviewed (R.R. #30, #31, #35 and #36). Findings include: Facility policy provided by Respiratory Therapy Supervisor (employee #9), on 08/27/2025 at 10:46 AM was reviewed. The policy was reviewed in February 2025, “Archivo de Documentos en Expediente Médico Cuidado Respiratorio”. The policy states that in section #1, the respiratory therapist will document all interventions performed with the patient, or any relevant situation with the patient, in the progress notes and/or any other document from the Respiratory Care Department and will keep them in the system, in the medical record always. 1. Five medical records were reviewed from 8/26/2025 to 8/28/2025 from 9:00 a.m. to 3:00 p.m. of patients receiving respiratory therapy and provided evidence that respiratory therapists were not documenting progress notes on all shifts for (R.R #30 #31, #35 and #36). The records reviewed provided evidence that patients received respiratory treatment in a timely manner, however, respiratory therapy staff failed to record progress notes related to the treatments provided. a)R.R #30 is a 68 year old female who was admitted on 08/21/2025 with a diagnosis of Acute Pneumonia, Hypoxemia, Bronchospasm. The record review was performed on 08/26/2025 through 08/27/2025 at 10:00 AM through 12:00 PM, with the respiratory therapist supervisor (employee # 9) and licensed pharmacist (employee #13), provided evidence that on 08/21/2025 at 8:00 AM the physician ordered Ipratropium-Albuterol [Duoneb] one AMP by power nebulizer every four hours. During the review, it was observed that on 08/21/2025, during the shifts from 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM, and on 08/23/2025, during the shift from 11:00 PM to 7:00 AM, the respiratory therapy staff did not document these administrations in the patient’s progress notes. b) R.R #30 is a 71-year-old female who was admitted on 08/20/2025 with a diagnosis of Clinical Pneumonia with Acute Bronchitis and Bronchospasm. The record review was performed on 08/26/2025 through 08/27/2025 at 10:00 AM through 12:00 PM, with the respiratory therapist supervisor (employee # 9) and licensed pharmacist (employee #13), provided evidence that on 08/20/2025 at 8:00 AM the physician ordered Proventil 0.083% one AMP / 3 ML AMP by power nebulizer every four hours and ordered Pulmicort 0.5MG / 2 ML one AMP by power nebulizer every twelve hours. During the review, it was observed that on 08/20/2025, during the shifts from 3:00 PM to 11:00 PM, and on 08/22/2025, during the shift from 3:00 PM to 11:00 PM, the respiratory therapy staff did not document these administrations in the patient’s progress notes. c) R.R #35 is a 2-year-old male who was admitted on 08/23/2025 with a diagnosis of Acute Pneumonia, Influenza. The record review was performed on 08/26/2025 through 08/27/2025 at 10:00 AM through 12:00 PM, with the respiratory therapist supervisor (employee # 9) and licensed pharmacist (employee #13), provided evidence that on 08/26/2025 at 12:01 AM the physician ordered Proventil 0.042% one AMP / 3 ML AMP by power nebulizer every four hours. During the review, it was observed that on 08/25/2025, during the shifts from 3:00 11:00 PM to 7:00 AM, the respiratory therapy staff did not document these administrations in the patient’s progress notes. d) R.R #36 is an 85-year-old female who was admitted on 08/15/2025 with a diagnosis of Pneumonia with Hypoxemia, Urinary Tract Infection (UTI) with Bacteremia. The record review was performed on 08/26/2025 through 08/27/2025 at 10:00 AM through 12:00 PM, with the respiratory therapist supervisor (employee # 9) and licensed pharmacist (employee #13), provided evidence that on 08/14/2025 at 10:00 PM the physician ordered Xopenex 1.25 MG / 3 ML AMP one AMP by power nebulizer every twenty minutes for three doses, then Xopenex 1.25 MG / 3 ML AMP one AMP by power nebulizer every four hours and ordered Atrovent 0.02% one AMP / 2.5 ML AMP every twenty minutes for three doses, then Atrovent 0.02% one AMP / 2.5 ML AMP every four hours. On 08/25/2025 at 1:59 PM the physician ordered Xopenex 0.63 MG / 3 ML AMP one AMP by power nebulizer every six hours. During the review, it was observed that on 08/14/2025, the therapy staff did not document a progress note for the initial assessment and respiratory treatment. On 08/15/2025, during the shift from 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM, and on 08/25/2025, during the shift from 7:00 AM TO 3:00 PM and 11:00 PM to 7:00 AM the respiratory therapy staff they did not document these administrations in the patient’s progress notes.”

“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 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials’ effort to maintain an integrated response during s disaster or emergency situation. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer ( employee #7) on 08/28/2025 at 11:00 AM it was noted that the facility failed to include emerging infectious diseases as part of the emergency plan.”

“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 08/28/2025 at 8:00 AM through 4:00 PM, 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 with the Safety Officer (employee #7) on 08/28/2025 at 11:00 AM it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the Hospital during and after an emergency.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(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:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #7) on 08/28/2025 it was noted that the facility failed to stablished policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §482.15(b)(6).”

“Arrangement with Other Facilities CFR(s): §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). [(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:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop arrangements with other facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to patients. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #7) on 08/28/2025 at 11:00 AM it was noted that the EP failed to have written arrangements with other dialysis facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to dialysis facilities.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to maintain documentation of all emergency preparedness training. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #7) on 08/28/2025 at 11:00 AM it was noted that the EP failed to provide documentation of training on emergency preparedness policies and procedures to all new and existing staff.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to conduct exercises to test the emergency plan every two years. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #7) on 08/28/2025 at 11:00 AM it was noted that the EP failed to conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise.”

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to implement the emergency power system inspection, testing, and preventive maintenance requirements found in the Health Care Facilities Code NFPA 99, NFPA 110, and Life Safety Code. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #7) on 08/28/2025 at 11:00 AM it was noted that the EP failed to present evidence of all required inspections and testing.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to mantain the width of aisles or corridors serving as exit acces at least 4 feet and maintained to provide the convenient removal of nonambulatory patients 19.2.3.4, 19.2.3.5. Findings include: 1. Approximately at 9:29 AM on 08/26/2025 unattended stretchers on both sides of the operating rooms hallway were observed reduceding exit access to two-foot six inches wide. 2. Approximately at 2:45 PM on 08/26/2025 an unattended linen cart, regular trash can and engineering department equipment car were observed on both sides of corrridor reduceding exit access to three-foot six inches wide. The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 47384 The facility failed to provide exit doors in the means of egress readily accessible and free of all obstructions or impediments to full instant use in the case of fire or other emergencies in accordance with the requirements of NFPA 101, 2012 Edition, Section 19.2.2.2.5.1, 19.2.2.2.5.2 and 19.2.2.2.6. Findings include: Approximately at 9:58 AM on 08/26/2025 the emergency exit door prior to the Surgery Area was observed with the door frame misaligned. This misalignment can cause malfunctioning and the door to not open easily or get stuck. The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire with the facility’s Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to mantain doors with self-closing devices as required on 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8. Findings include: 1.Approximately at 11:45 AM on 08/26/2025 it was observed that the smoke barrier door in hallway between Emergency Department and Radiology did not close flush. 2. Approximately at 12:10 PM on 08/26/2025 it was observed that the self-closing device on smoke barrier door on the second floor anex area was held opened, no automatic release operational. The finding was verified by the Safety Officer and Engineering Department Manager 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 with the facility’s Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to ensure exit and directional exit signs were provided and means of egress marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants in accordance with NFPA 101, 2012 Edition, Section 19.2.10.1 and 7.10. Findings include: 1. Observation and interview on 08/26/2025 at approximately 9:30 AM on the Surgery Department it was noticed that no exit sign were provided in the operating rooms hallway area stating means of egress from the area. 2. Observation and interview on 08/26/2025 at approximately 10:30 AM, no exit sign stating obvious egress path was observed on corridor “Pasillo Sur” of Emergency Ward (cubicles 1 through 6). 3. Observation and interview on 08/26/2025 at approximately 10:30 AM, no exit sign was observed on either doors of Radiology department hallway. 4. Observation and interview on 08/27/2025 at approximately 9:30 AM, on the Medice third floor a exit sign was observed mounted backwards. 5. Observation and interview on 08/27/2025 at approximately 10:45 AM, on the pediatry deparment hallway, no exit sign was observed. 6. Observation and interview on 08/27/2025 at approximately 11:00 AM, an un energized exit sign (not lit) was observed in front of the elevator. The finding was verified by the Safety Officer and Engineering Department Manager 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 observations made during the survey for life safety from fire with the facility’s Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to maintain Hazardous areas protected by a fire barrier having 1-hour fire resistance rating in accordance with 8.7.1 or 19.3.5.9. Findings include: 1. On 08/26/2025, approximately at 9:47 AM, in the machine area of the autoclaves in the operating room, it was observed that the gypsum board wall dividing the area showed perforations and did not cover completely around the autoclave. This deficiency would not provide the required protection for a hazard area according to code. The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 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 Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to mantain Alcohol Based Hand Rub Dispenser (ABHR) protected in accordance with 8.7.3.1. Findings include: 1. Observation and interview on 08/26/2025 at approximately 11:15 AM, in the Triage area (Triage 1) on Emergency Ward, ABHR was observed on above a electric receptacle. 2. Observation and interview on 08/26/2025 at approximately 1:30 PM, on the third floor anex, ABHR was observed on above a electric receptacle between rooms #323 and #324. The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 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 Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to maintain initiation devices in all areas. Findings include: 1. On 08/26/2025, approximately at 9:47 AM, in the medicine room of third floor, no smke detector was found. 2. On 08/26/2025, approximately at 10:47 AM, in the Physichal Therapy area, no smke detector was found. 3. On 08/26/2025, approximately at 2:47 PM, in the Intensive Care Unit, no smoke detectors were observed in 6 of the rooms. 4. On 08/27/2025, approximately at 10:00 AM, in the Respiratory Therapy Unit, no smoke detector was observed. . The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Fire Alarm System - Notification CFR(s): NFPA 101 Fire Alarm - Notification 2012 EXISTING Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire. 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(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 Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to ensure that occupant notification is provided automatically in accordance with NFPA 101, 2012 Edition, Section 9.6.3 by audible and visual signals. Findings include: Observation and interview on 08/26/2025 through 08/27/2025 revealed that there are no visual (strobe) or audible signals in public bathrooms (Surgery Recovery ). The finding was verified by the Safety Officer and Engineering Department Manager 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 observations made during the survey for life safety from fire with the facility’s Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to maintain the system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection. Findings include: 1. Observation and interview on 08/26/2025 at approximately 11:30 AM, on the waiting area of Emergey Ward, it was observed that 6 out of 6 sprinkler heads were covered by excessive dust (Loaded Sprinklers). 2. Observation and interview on 08/26/2025 at approximately 1:30 PM, on Pediatric Ward, loose squetcheon was observed in front of cubicle #1. 3. Observation and interview on 08/26/2025 at approximately 1:30 PM, on Pediatric Ward, missing squetcheon were observed in the area. 4. Observation and interview on 08/27/2025 at approximately 2:30 PM, revealed that report named “Riser Inspection” stated that Water Motor Gong was inoperative. The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 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 Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), the facility failed to secure that Portable Fire Extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10. Findings include: 1. On 08/26/2025 approximately at 9:00 AM A fire extinguisher was observed blocked by a stretcher in the hallway of the operating rooms. 2. On 08/26/2025 approximately at 10:30 AM a fire extinguisher was observed blocked by a dirty linnen cart in front of the environmental care and management room. 3. On 08/26/2025 approximately at 10:30 AM a fire extinguisher was observed obstructed by a counter top and papers between Blood Bank and Hematology area in the Laboratory Department. 4. On 08/27/2025 approximately at 9:30 AM a fire extinguisher was observed obstructed by a regular trash can in the Intensive Care Unit. The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. 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 Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to protect corridors at clinical floors (doors do not latch) as required by the 2012 edition of the Life Safety Code of the NFPA Section 19.3.6.3. Findings include: During the tour for life safety from fire on 08/26/2024 through 08/27/2024 from 8:00 AM through 4:00 PM, patient’s sleeping room doors were tested it was found that patient’s sleeping rooms do not latch when the doors are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request. Second floor: #201, #202, #203, #204, #206, #207, #208, #209, #210, #211, #214, #215, #216 Third floor: #306, #312, #314, #316, #319, #320, #322, #323, #324, #325, #326, #327, #328, #329, #330, #331, #332 Fourth floor: #402, #403, #404, #406, #407, #407, #409, #410 The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Gas and Vacuum Piped Systems - Warning System CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Warning Systems All master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable. 5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations and document review made during the survey for life safety from fire on 08/19/2025 through 08/21/2025 from 8:00 AM to 4:00 PM, it was determined that the facility failed to ensure all master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable. 5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99) Findings include: 1. A pattern of non labeling the Medical Gas outputs was observed throughout the facility. 2. A pattern of non labeling the Medical Gas Shutoff valves was observed throughout the facility. The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) 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 Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to ensure Essential Electrical System (EES) is maintained by conducting three-year four-hour load bank test in accordance with the requirements of NFPA 99, 2012 Edition Section 6 and NFPA 110, 2012 Edition Section 8.4.9. Findings include: Document review and interview on 08/26/2025 at approximately 3:05 PM the documents reviewed did not evidencea a 36 month test for the EES. The finding was verified by the Safety Officer and Engineering Department Manager 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 with the facility’s Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to observe precautionary measures to ensure safety on the cylinder storage as requested on 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) Findings include: Unprotected cylinders were observed in the Medical Gas Cage: 1. Twenty eight (28) Type E Oxygen tanks were observed un chained, unsecured. 2. Forty (40) Type H Nitrous Oxide tanks were observed un chained, unsecured. 3. Five (5) Type H Nitrogen tanks were observed un chained, unsecured. 4. Seventeen (17) Type H Oxigen tanks were observed un chained, unsecured 5.Three (3) Type H Helium tanks were observed un chained, unsecured The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”