Ryder Memorial Hospital Inc.

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 51637 Based on the review of personnel credential files (CF) and State Law License regulations requirements, it was determined that the facility failed to updated personnel credential files related to professional staff comply with the annual evaluation. Findings include: 1. During the credential files review of rehabilitation and outpatient staff conducted on 12/11/2025 from 9:18 AM to 11:00 AM accompanied by the human resources manager (employee #12), the following was found: a. 2 of 3 employees file reviewed did not have annual evaluation. i. C.F. #1 do not have annual evaluation since 09/2018. ii. C.F. #2 has never been evaluated. b. In an interview with employee #12, she stated that these employees do not have an annual evaluation because these programs have not had a manager since 2022. 51782 2. During the credential files review of emergency room department nurses staff with Human Resources supervisor (employee # 44), performed on 12/11/2025 from 10:45 AM to 12:00 PM, the following was found: a) Two out of eight credential files failed to show updated evidence of the annual evaluation (N.C.F. #5 last evaluation on 02/09/2022 and #6 last evaluation on 06/21/2023). b) (N.C.F #8), has a registered nurses license expired on 08/02/2025. (Employee #12), took immediate action and removed the employee from his duties until he renewed his license.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 51629 Based on interviews with the hospital Admission Department Supervisor (employee # 41) and records reviewed (RR) performed from 12/09/2025 at 10:00 AM, 12/10/2025 at 1:30 PM and 12/11/2025 at 8:30 AM, it was determined that the facility failed to implement and maintain a procedure for the notification and delivery of the Patient’s Notice of Rights. This deficient practice was identified in 3 out of 18 open and closed records reviewed (RR # 15, #30, and # 39). Findings include: During an interview with the Admission Department Supervisor (employee # 41) on 12/09/2025 at 9:00 AM, she stated that during the admission procedure, the documents to be provided to patient and relative contain the notice of rights. 1. An open and closed RR was done from 12/09/2025 through 12/11/2025. a. RR # 15 is an 82-year-old male who was admitted on 12/03/2025 with a diagnosis of Acute Gastroenteritis, Moderate Dehydration, Acute Renal Failure and Type II NSTEMI. During record review performed on 12/11/2025, the patient was still hospitalized but the clinical record did not evidence that a copy of the notice of rights was provided to the patient or patient’s representative. b. RR # 30 is a 93-year-old female who was admitted on 11/26/2025 with a diagnosis of Symptomatic Anemia and HTN Dyslipidemia. During record review performed on 12/09/2025, the patient was still hospitalized but the clinical record did not evidence that a copy of the notice of rights was provided to the patient or patient’s representative. c .RR # 39 is a 70-year-old female who was admitted on 11/28/2025 with a diagnosis of Aspiration Pneumonia and Mycoplasma. The patient was discharged home on 12/04/2025. The clinical record did not evidence that a copy of notice of rights was provided to the patient or patient’s representative. The facility did not maintain and demonstrate evidence that, during the admission process, the procedure for the notification and delivery of the patient’s notice of rights is clearly explained to patients or representatives.”

“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: 51629 Based on interviews with the Discharge Planning staff (employees # 5 and # 6), documents reviewed, and six open and closed records reviewed (RR) performed on 12/10/2025 at 1:30 PM, it was determined that the facility failed to inform each patient of their rights, in advance of furnishing or discontinuing patient care. This deficient practice was identified in 3 out of six cases reviewed (RR # 39, # 40 and # 41). Findings include: 1. RR # 39 is a 70 -year-old female Medicare beneficiary who was admitted on 11/28/2025 with a diagnosis of Aspiration Pneumoniae. The patient was discharged home on 12/04/2025. a. The clinical record did not evidence that a copy of an updated Medicare Important Message was provided two days before discharge. 2. RR # 40 is a 65-year-old female Medicare beneficiary who was admitted on 11/1/2025 with a diagnosis of Right Leg Fracture. The patient was discharged by transfer to a day care home on 11/6/2025. a. The clinical record did not evidence that a copy of an updated Medicare Important Message was provided two days before transfer. 3. RR # 41 is an 80-year-old male Medicare beneficiary who was admitted on 11/14/2025 with a diagnosis of Renal Failure and Pneumoniae. a. The clinical record did not evidence that a copy of an updated Medicare Important Message was provided within 2 days of admission. The facility failed to inform each patient of their rights, in advance of furnishing or discontinuing patient care.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 51629 Based on interviews with the hospital Director of Nursing (employee # 1), the head nurse of Medicine / Surgery ward (employee # 3) and records reviewed (R.R.) performed on 12/11/2025 at 9:30 AM, it was determined that the facility failed to implement and maintain a procedure for the participation of patient or his representative in the development and implementation of his or her plan of care. This deficient practice was identified in 2 out of 2 open records reviewed (RR # 15 and # 41). Findings include: During an interview with the Director of Nursing (employee # 1) performed on 12/11/2025 at 9:30 AM, she stated that the nursing policy for patient restriction and/or seclusion stipulates that in every event where a restriction is needed, the family will be notified regarding the application of the restriction and the reason for it. The policy named: “Protocolo para Restricción” Protocol for Restraint (07/2024 revision) was reviewed on 12/11/2025 at 9:30 AM. The facility policy states that the family will be notified of the application of restrictions and the reason for it. 1. R.R. was performed with Medicine / Surgery ward head nurse (employee # 3 on 12/11/2025 at 9:30 AM. a. RR # 15 is an 82-year-old male who was admitted on 12/03/2025 with a diagnosis of Acute Gastroenteritis, Severe Dehydration and Renal Failure. On 12/3/2025 the primary physician ordered the application of soft restrictions on the upper extremities. The procedure was performed by the registered nurse on 12/03/2025 at 11:00 AM and reassessments were done every two hours from that day until 12/04/2025 at 9:00 AM when the soft restrictions were discontinued. No evidence of family or legal representative notification was present in the medical record. b. RR # 41 is an 80-year-old male who was admitted on 11/14/2025 with a diagnosis of Renal Failure and Pneumoniae. On 11/15/2025 at 3:00 PM the primary physician ordered the application of soft restrictions on the upper extremities. The procedure was performed by the registered nurse on 11/15/2025 at 4:00 PM and reassessments were done every two hours from that day until 11/16/2025 at 3:00 PM when the soft restrictions were discontinued. No evidence of family or legal representative notification was present in the medical record. 2. The facility failed to demonstrate the protection of the right of the patient (or patient’s representative) to participate in the development and implementation of his or her plan of care in the event of application of patient’s restriction or seclusion.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 51782 Based on open and closed records reviewed (R.R), advance directive policy and procedure and interviews, it was determined that the facility failed to ensure that patients or their representatives formulate advance directive and comply with these directives related to lack of physician order and justification for the consent of Do Not Resuscitate DNR, Do Not Intubate (DNI) and advance directive orientation for 6 out of 21 records reviewed (RR # 10, # 15, #30, #39, # 40 and #53). Findings include: Facility policy provided by Emergency Room Manager (employee #39), on 12/10/2025 at 1:16 PM was reviewed. The policy was reviewed in 01/2025, “Directriz de no resucitar (DNR) y/o no entubar (DNI)”. The policy states on page 1, section 6 that the primary care physician will meet with the patient and/or family members for guidance and to obtain the signed consent form for the DNR or DNI. This will be documented as a medical order and in the patient’s medical progress note. 1. R.R #53 is a 63-year-old male who was brought at emergency room on 12/08/2025, due to aspiration pneumonia, sepsis. During record review performed on 12/09/2025, at 3:30 P.M., revealed a consent to Do Not Intubation (DNI) and Do Not Resuscitate (DNR), signed by a family member on 12/09/2025 at 10:02 AM. However, no evidence of a DNR/DNI medical order was found in the system or in writing, nor of an initial progress note from the physician justifying the DNR/DNI and family guidance of the DNR/DNI. 51629 2. During an interview with the Admission Department Supervisor (employee # 41) on 12/09/2025 at 9:00 AM, she stated that during the admission procedure, the documents to be provided to patient and relative contain all their rights, including the procedure for submission of advanced directives. 3. An open and closed record review was done from 12/09/2025 through 12/11/2025. a. RR # 10 is a 92-year-old female who was admitted on 11/14/2025 with a diagnosis of Pneumonia and Dementia. During record review performed on 12/09/2025, the patient was still hospitalized but the clinical record did not evidence that a copy of the procedure for advanced directives submission was provided to the patient representative. b. RR # 15 is an 82-year-old male who was admitted on 12/03/2025 with a diagnosis of Acute Gastroenteritis, Moderate Dehydration, Acute Renal Failure and Type II NSTEMI. During record reviewed performed on 12/11/2025, the patient was still hospitalized but the clinical record did not evidence that a copy of the procedure for advanced directives submission was provided to the patient’s representative. c. RR # 30 is a 93-year-old female who was admitted on 11/26/2025 with a diagnosis of Symptomatic Anemia and HTN Dyslipidemia. During record review performed on 12/09/2025, the patient was still hospitalized but the clinical record did not evidence that a copy of the procedure for advanced directives submission was provided to the patient’s representative. d. RR # 39 is a 70-year-old female who was admitted on 11/28/2025 with a diagnosis of Aspiration Pneumonia and Mycoplasma. The patient was discharged home on 12/04/2025. The clinical record did not evidence that a copy of the procedure for advanced directives submission was provided. e. RR # 40 is a 65-year-old female who was admitted on 11/01/2025 with a diagnosis of Right Leg Fracture. The patient was discharged by transferring to a nursing home on 11/06/2025. The clinical record did not evidence that a copy of the procedure for advanced directives submission was provided. The facility did not maintain and demonstrate evidence that, during the admission process, the procedure for submitting advance directives is clearly explained to patients or representatives.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47632 Based on observations made in the patient changing room area from 12/09/2025 to 12/12/2025 from 9:30 AM to 3:00 PM, it was determined that the facility failed to ensure a safe environment by not responding promptly to the nurse’s call in the patient bathroom. Findings include: 1. On 12/09/2025 at 9:59 AM, the nurse call button in the patient changing room bathroom was activated, and it took 16 seconds for nursing staff to respond. 2. On 12/11/2025 at 9:43 AM, the nurse call button was activated in the bathroom of delivery room #1, it took the nursing staff 37 seconds to respond. The facility failed to provide a safe environment, exposing the patient to the risk of falls or adverse incidents.”

“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: 51629 Based on interviews with the Director of Nursing (DON) (employee # 1), and document review performed on 12/11/2025 at 1:30 PM, it was determined that the facility failed to have a policy and procedure that address responsibilities and systems for identifying restraint / seclusion associated deaths according to CMS requirements. Findings include: The policy named: “Protocolo para Restricción” Protocol for Restriction (07/2024 revision) was reviewed on 12/11/2025 at 1:30 PM with the DON. 1.The facility policy does not state that is a mandatory requirement the report to CMS of every death associated to restraint / seclusion. Neither includes a specific criteria of which deaths must be reported and the procedure to be followed.”

“PATIENT RIGHTS: INTERNAL DEATH REPORTING LOG CFR(s): 418.13(g)(2), (3)(ii), (4) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (2) When no seclusion has been used and when the only restraints used on the patient are those applied exclusively to the patient’s wrist(s), and which are composed solely of soft, non-rigid, cloth-like materials, the hospital staff must record in an internal log or other system, the following information: (i) Any death that occurs while a patient is in such restraints. (ii) Any death that occurs within 24 hours after a patient has been removed from such restraints. (3) [The staff must document in the patient’s medical record the date and time the death was:] (i) Recorded in the internal log or other system for deaths described in paragraph (g)(2) of this section. (4) For deaths described in paragraph (g)(2) of this section, entries into the log or other system must be documented as follows: (i) Each entry must be made not later than seven days after the date of death of the patient. (ii) Each entry must document the patient’s name, date of birth, date of death, name of attending physician or other licensed practitioner who is responsible for the care of the patient medical record number, and primary diagnosis(es). (iii) The information must be made available in either written or electronic form to CMS immediately upon request. This Standard is not met as evidenced by: 51629 Based on interviews with the Director of Nursing (DON) (employee # 1), and document reviewed performed on 12/11/2025 at 1:30 PM, it was determined that the facility failed to have a policy and procedure that address responsibilities and systems for identifying restraint / seclusion associated deaths according to CMS requirements. Findings include: 1. The policy named: “Protocolo para Restricción” Protocol for Restriction (07/2024 revision) was reviewed on 12/11/2025 at 1:30 PM with the DON. a. The facility policy does not state that staff must record in an internal log every death associated to restraint / seclusion. Neither includes a specific criterion of which deaths must be recorded in the internal log and the procedure to be followed for each entry. b.The information (internal log) was requested on 12/09/2025 at 8:56 AM but at the time of the completion of the survey, the document was not provided.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 51829 Based on the review and interview conducted on December 12, 2025, at 1:30 p.m. with the Quality Coordinator (employee #26) ,it was determined that the facility did not ensure compliance with submitting data in certain areas that demonstrate the quality of care and services, thus failing to guarantee data entry in the Medicare quality report as required. Findings include: The findings of the November 26, 2025, comparison were discussed on December 12, 2025 at 1:30 PM with the Quality Coordinator and the following was found: 1. The facility does not submit the overall star rating, which is based on performance in different quality areas. 2. The facility does not submit the rating from the patient survey that measures patient experience with the care received.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 47632 Based on interviews conducted with the operating room manager (employee #15), anesthesia supervisor (employee #19), child health manager (employee #23), and anesthesia supervisor (employee #19) from 12/09/2025, to 12/11/2025, it was determined that the facility failed to ensure the integration of infection control indicators into quality indicators. Findings include: 1. During the interview with the operating room manager (employee #15) on 12/10/2025 at 11:00 AM, she stated that infection control was not included in her quality indicators. 2. During the interview with the anesthesia supervisor (employee #19) on 12/10/2025 at 1:30 PM, she stated that infection control was not included in her quality indicators. 3. During the interview with the maternal and child health manager (employee #23) on 12/11/2025 at 1:21 PM, she stated that infection control was not included in her quality indicators. The facility failure by not including infection control in quality indicators.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 47632 Based on interviews with the operating room head nurse (employee #15), the anesthesia supervisor (employee #19), and the child health director (employee #23), between 12/09/2025 to 12/11/2025 from 8:00 AM to 3:30 PM, it was determined that the facility failed to maintain incident and accident records. Findings include: 1. During interviews conducted with the head nurse (employee #15), the anesthesia supervisor (employee #19), and the child health director (employee #23) from December 9, 2025, to December 11, 2025, they stated that when an incident occurs, it is recorded in writing and submitted to the risk management coordinator. They pointed out that the incident report form has the words “do not photocopy” printed on it. The risk management coordinator (employee #46) was interviewed on 12/10/2025 at 11:45 AM, who stated that staff report the incident, she receives it and conducts investigations. On 12/10/2025 at 2:10 PM, she created a form for staff to obtain evidence of incidents reported to risk management.”

“QAPI PERFORMANCE IMPROVEMENT PROJECTS CFR(s): 482.21(d) As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must be proportional to the scope and complexity of the hospital’s services and operations. (2) A hospital may, as one of its projects, develop and implement an information technology system explicitly designed to improve patient safety and quality of care. This project, in its initial stage of development, does not need to demonstrate measurable improvement in indicators related to health outcomes. (3) The hospital must document what quality improvement projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. (4) A hospital is not required to participate in a QIO cooperative project, but its own projects are required to be of comparable effort. This Standard is not met as evidenced by: 51829 Based on the review and interview conducted on December 12, 2025, at 2:00 pm with the Quality Coordinator (employee #26), it was determined that the facilities did not ensure compliance with performance improvement projects. Findings include: The submitted project lacks a formal documentation process to demonstrate the efforts made and does not meet the scope required to evaluate the improvement.”

“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: 51629 Based on interviews with the Discharge Planning staff (employees # 5 and # 6) performed on 12/10/2025 at 1:25 PM and document review performed on 12/10/2025 at 1:30 PM, it was determined that the facility failed to develop, implement and maintain an effective, ongoing, data-driven quality assessment and performance improvement program (QAPI) for discharge planning program. Findings include: 1. During interviews with the Discharge Planning staff (employees # 5 and # 6) and document review performed on 12/10/2025 at 1:30 PM, they stated that they maintain statistics and tables with the record of all patients treated but did not provide quality indicators on aspects to be monitored. 2. During interview with the Hospital Quality Coordinator (employee # 26) and document review performed on 12/10/2025 at 2:00 PM, no information was provided about quality indicators for the year 2025 on aspects to be monitored, including the delivery of Medicare Important Message. The facility did not maintain and demonstrate evidence of its quality assessment and performance improvement program (QAPI) for the Discharge Planning Program.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 51829 Based on review of eleven Medical Staff Credential Files (MSFs) on December 11, 2025, at 2:11 pm and interview with Medical Director (employee #38), it was determined that the hospital did not ensure the periodic re-evaluation of health certificates, cardiopulmonary resuscitation (CPR), and hepatitis vaccination. Findings include: 1. During a review of the credential files of eleven medical professionals, conducted on November 12, 2025, at 2:11 p.m., expired credentials were identified. These credentials included: a. Expired medical certificates for employees #9, #10, and #11; expired CPR for employees #7, #10, and #11; and no evidence of hepatitis vaccination and/or hepatitis vaccination titers for employees #7 and #11. The hepatitis vaccination cannot be waived. Expired credentials are documented on the medical staff credentials sheet.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 51829 Based on the review conducted during the visit to the hospital facilities, compliance with best supervisory practices was not guaranteed regarding standards and policies related to hospital and unit procedures, safety, and nursing services. Findings include: 1.On December 12, 2025, at 9:30 a.m., the registered nurse (employee #34) administered Lovenox subcutaneously and recapped the syringe. The CDC, in its statement titled “Centers for Disease Control and Prevention.” United States Department of Health and Human Services. October 4, 2019. Archived from the original on April 10, 2020. Retrieved May 15, 2020, indicates that disease control and prevention, including professionals and their practices in medication administration, prohibits recapping. 2. On December 12, 2025, at 2:44 pm, during a visit to the newborn nursery, a nurse (employee #28) was observed feeding a newborn without holding the baby in her arms. The hospital’s Safe Bottle-Feeding Policy, which is undated but referenced to 2023, prohibits wedging bottles, stating the reasons why bottles should not be wedged, the consequences, and clearly indicating that the baby should be fed while being held. The nursing supervisor, along with the Infection Control Officer (employee #33), immediately provided evidence of training on the policy to all nursing staff in the unit. 3. On November 12, 2025, at 10:55 a.m., during a visit to the chemotherapy administration room, the nursing professional (employee #36) was observed placing unlabeled 0.9% saline syringes on the treatment cart without using a barrier to prevent contamination. The World Health Organization, in its document entitled WHO Technical Report Series No. 957, 2010, outlines guidelines for the safe preparation of medications, including aseptic techniques and labeling, among other things. These guidelines were disregarded following intervention by the quality coordinator (employee #26), who also developed a plan to improve practices in conjunction with the unit manager. 4. During the rounds of the units, the nursing professionals exhibited poor hand hygiene practices and inadequate use of personal protective equipment such as gloves and gowns. Employees in the medical-surgical units, the neonatal ward, and the chemotherapy ward use gloves and, once discarded, do not wash their hands. They enter patient rooms wearing gloves and do not change them for patient interventions. Handwashing time is not within the established timeframe, and they reuse the same gown between babies in the neonatal ward. The hospital’s established Hand Hygiene policy # 3.1 dated 05/27/2022, outlines the correct handwashing and glove use procedures. The unnumbered PPE usage standard, titled “Use of Isolation Gowns in the NICU, Nursery, and Delivery Room,” dated 12/12/2025, states in its procedure that gowns should not be reused between patients.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 47632 Based on observations made in the operating room with head nurse (employee #16) and anesthesia supervisor (employee #19) from 12/09/2025, to 12/11/2025, from 8:00 AM to 3:30 PM, it was determined that the facility failed to ensure the supervision of expired medications in the anesthesia medication cart. Findings include: During observations made in operating rooms 1, 2, 3, and 4, the following were noted: 1. On 12/10/2025 at 10:17 AM, the following expired medications were observed in operating room #2: a. Five vials of Atropine 0.4 milligrams (mg)/milliliter (ml) expired 11/2025 and 03/2025 were observed. b. One vial of Epinephrine sulfate 50mg/ml expired 09/2025 was observed. c. One vial of Metoclopramide 10 mg/2 ml expired 11/30/2025 was observed. 2. On 12/10/2025 at 1:30 PM, the following expired medications were observed in the malignant hyperthermia cart: a. Two vials of Dextrose 50% 25 grams (g)/50 ml expired 1/1/2025 were observed.”

“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: 51782 Based on close, active and transfer clinical records reviewed (R.R) from 12/09/2025 through 12/12/2025, it was determined that the facility failed to ensure that all patient medical record entries must be legible, complete, dated, timed, and authenticated in writing or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedure, related to lack of documentation of transfer consent, nursing notes and vital signs on the transfer document 2 out of 59 Records Reviewed (RR. #55 and 56, ) Findings include: Facility policy provided by Emergency Room Manager (employee #39), on 12/09/2025 at 1:41 PM was reviewed. The policy was reviewed in 81/2023, “Traslado de paciente a otra institución hospitalaria”, Transfer of patients to Another Institutions. The policy states on page 3, section 4 that the physician will obtain informed consent from the patient, family member, or authorized personnel for the transfer by having them sign document RM-619, “Informed Consent for Transfer to Another Hospital.” A copy of this document must be included with the transfer documents. 1. R.R #55 is a 24-year-old female who was admitted on 10/20/2025 to the emergency room (ER) due to a car accident, trauma to abdomen and left arm, who transferred to another institution hospital in Rio Piedras , due to diagnosis of Intraabdominal Bleeding. a) During the record review performed on 12/09/2025 at 2:50 PM revealed, no consent for the transfer signed by the patient and/or family member was found, and no notes related to nursing interventions were found. 2. R.R #56 is a 46-year-old female who was admitted on 12/03/2025 to the emergency room (ER) with a diagnosis of abdominal pain, nauseas, who transferred to another institution, hospital in Caguas, due to diagnosis of Stroke. a) During the record review performed on 12/09/2025 at 3:10 PM revealed, no consent for the transfer signed by the patient and/or family member was found.”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 51629 Based on interviews with the Intensive Care Unit Supervisor (employee # 48), Gynecology and Pediatric Unit Supervisor (employee # 49), document review and record review performed on 12/09/2025 at 10:00 AM, it was identified that the facility failed to execute informed consent forms for procedures and treatments specified by medical staff, or by federal or state law if applicable, to require written patient consent with the minimum elements of a properly executed informed consent. This deficient practice was identified in 3 out of 7 cases reviewed (RR # 30, RR# 31 and RR # 36). Findings include: A record review with Intensive Care Unit Supervisor (employee # 46) was performed on 12/09/2025 at 10:00 AM and with Gynecology and Pediatric Unit Supervisor (employee # 47) on 12/09/2025 at 10:45 AM. 1. RR # 30 is a 93-year-old female who was admitted on 11/26/2025 with a diagnosis of Symptomatic Anemia and HTN Dyslipidemia. On 9/2/2025 at 5:25 PM, a surgery consent form was documented, signed and dated by the surgeon and patient representative. The document states that the patient was going to undergo the following surgery: C + D Left Hip Ulcer. The clinical record includes an anesthesia permission form named: “Consentimiento para la Administración de Anestesia” Consent to Administration of Anesthesia. It is signed by the patient’s representative but not dated (nor date and time), nor signed and dated by the anesthesiologist. 2. RR # 31 is a 53-year-old male who was admitted on 08/05/2025 with a diagnosis of Acute Perforated Appendicitis. a. On 08/07/2025 the patient underwent the following surgery: Open Gastrostomy and Open Tracheostomy. The clinical record includes a surgery consent named: “Consentimiento Informado para Cirugía y/o Tratamiento Médico Específico que conlleve riesgo” Informed Consent for Surgery and/or Specific Medical Treatment Involving Risk. It is signed by the patient’s representative but not signed nor dated (date and time) by the surgeon. b. On 09/16/2025 the patient underwent another surgery. The clinical record includes a surgery consent named: “Consentimiento Informado para Cirugía y/o Tratamiento Médico Específico que conlleve riesgo”. It is signed by the patient’s representative but not signed nor dated (date and time) by the surgeon. Also, the electronic health record (EHR) shows an anesthesia consent form signed by patient’s representative but not signed nor dated (date and time) by the anesthesiology. 3. RR # 36 is a 20-year-old female who was admitted on 12/08/2025 with a diagnosis of Intrauterine Pregnancy (IUP) 39 weeks. a. On 12/08/2025 the patient underwent the following surgery: Cesarean Section. The clinical record includes surgery consent signed by the patient and surgeon (obstetrician) but not completely dated (time) by the last. Also, the electronic health record includes an anesthesia consent form signed by both the patient and anesthesiology but not completely dated (time) by the last. The facility failed to execute informed consent forms for procedures and treatments.”

“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 spinal cart and cardiovascular laboratory with Head Nurse (employee #16), Registered Nurse (employee #17), and anesthesia supervisor (employee #19) from 12/09/2025 to 12/12/2025 from 8:00 a.m. to 3:30 p.m., it was determined that the facility failed to ensure that the medications in the anesthesia cart were secured. Findings include: During observations made in the operating room area, the following were found: 1. On 12/09/2025 at 10:48 AM, ten vials of Bupivacaine were observed in the spinal anesthesia cart, accessible to unauthorized personnel or patients. 2. On 12/09/2025 at 11:26 AM, it was observed that the anesthesia cart was open with high-risk medications accessible to unauthorized personnel or patients.”

“CONTROLLED DRUGS KEPT LOCKED CFR(s): 482.25(b)(2)(ii) Drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970 must be kept locked within a secure area. This Standard is not met as evidenced by: 51782 Based on policies reviewed and observations made in the Emergency Room Department, from 12/09/2025 to 12/12/2025 from 8:30 AM to 3:30 PM, it was determined that the facility failed to maintain controlled medication category V in a secure area. Findings include: Facility policy provided by Emergency Room Manager (employee #39), on 12/09/2025 at 1:41 PM was reviewed. The policy was reviewed in 01/2024, “Control de sustancias controladas en las unidades clínicas” Control of Controlled Substances in Clinical Units. The policy states on page 1, section 2 that the controlled substances will be stored in a double-locked safe with a key. Facility policy provided by Emergency Room Manager (employee #39), on 12/09/2025 at 1:41 PM was reviewed. This policy was reviese in 01/2024, “Sobrantes o residuos de sustancias controladas” Leftovers of residues of Controlled Substances. The policy states on page 1, section 2 that all surplus deposits must be documented on the controlled substance surplus record sheet. 1. During observations conducted in the Emergency Room Department with Emergency Room Manager (employee #39) and Quality Coordinator (employee #11), on 12/09/2025 from 8:30 AM to 3:30 PM, the following was observed: a) At 9:20 AM, in the medicine room, a bottle of Phenergan with codeine with residual is found outside the narcotics box, on a table inside a tray labeled “Omnicell Surplus ER”. During an interview with the registered nurse (employee #47), in charge of the narcotics box, on 12/09/2025, at 9:30 AM, she stated that she was unaware that the bottle was there. During an interview with the emergency room manager (employee #39) on 12/09/2025, at 9:35 AM, she stated that the pharmacy department had not been notified, and no report had been filed regarding the discovery.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 51637 Based on the observational tour performed on 12/09/2025 from 8:40 AM till 9:30 AM of the facility’s kitchen that prepares patient’s meals, review of menus and policies/procedures and interview, it was determined that the facility failed to store, maintain and prepare food in a safe and sanitary manner. Findings include: 1. The following was found during the observational tour of the facility’s kitchen on 12/09/2025 from 8:40 AM till 9:30 AM: a. In the dry food storage area, cans of beans, rice, and dirt were found under the cupboards. b. In the fruit and juice refrigerator, an open cantaloupe covered with no use-by or expiration date and four cups of orange juice were found under the shelves, as well as a food item with an expired use-by date. c. Open vegetables were found on the floor in the meat freezer.”

“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: 47632 Based on observations made in pre-anesthesia, operating room (OR), recovery, cardiovascular laboratory, delivery, imaging center, rehabilitation area and cesarean section room with Head Nurse OR (employee #16), Head nurse Delivery (employee #22) and Maternal and Child health manager (employee #23) from 12/09/20250 to 12/12/2025 from 8:00 a.m. to 3:00 PM, it was determined that the facility failed to ensure that the medical equipment in the operating room received preventive maintenance and maintain the building areas in optimal condition including the prevention of leaks in roofs and walls. Findings include: During the observations made, the following were found: 1. Pre-anesthesia area: a. On 12/09/2025 at 10:04 AM, two patient warmers were observed without preventive maintenance. b. On 12/09/2025 at 10:06 AM, two cardiac monitors were observed without preventive maintenance. 2. Operating room: a. On 12/09/2025 at 10:44 AM, 1 out of 4 anesthesia machines were observed without preventive maintenance. 3. Cardiovascular laboratory: a. On 12/09/2025 at 11:24 AM, defibrillator was observed without preventive maintenance. 4. Recovery: a. On 12/09/2025 at 11:24 AM, 6 out of 6 cardio monitors were observed without preventive maintenance. 5. Delivery: a .On 12/11/2025 at 9:35 AM, an infusion machine was observed without preventive maintenance. b. On 12/11/2025 at 9:45 AM, it was observed that four of the four delivery rooms, as well as one cesarean section , lacked preventive maintenance on pediatric scales. The facility failed to provide documented evidence of preventive maintenance, which represents a risk to patient safety. 51637 6. During the Imaging center tour performed on 12/09/2025 from 9:00 AM till 11:00 AM accompanied by the imaging center manager (employee #9), the following was observed: a) Acoustics with noticeable appearance of humidity and filtration. b) Loose and missing tile baseboards. c) Mold on acoustics panels and light bulbs. d) Walls with noticeable moisture retention and peeling paint. e) Walls with holes without covering or paint. f) Missing acoustic panels in the CT area. g) Treatment room doors with peeling paint. 7. During the rehabilitation and outpatient area tour performed on 12/10/2025 from 1:20 PM till 1:45 PM accompanied by the physical therapist (employee #10), the following was observed: a. Acoustics with noticeable signs of moisture and water seepage on the floor. b. Loose and missing tile baseboards. 47384 8. During the observations made on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), the following was observed: a. Broken Steris Lamp on OR #1 b. 4 surgical area lavatories were observed, two (2) out of four (4) do not work and one was observed with peeled porcelain. c) Doors on four (4) Operating Rooms on the Surgical Ward were found not to close flush to frame. d) Epoxy flooring in front of OR #3 was observed with exposed cement. e) Epoxy flooring in front of lavatory of OR rooms #3 and #4 was observed with exposed cement. f) Air Conditioning (AC) Vents with excessive dust in Pre Delivery #1 g) Shower curtain in Pre Delivery #2 was found to be plastic and does not provide safety in case patient having to hold from curtain. h) Air Conditioning (AC) Vents with excessive dust in NICU i) Air Conditioning (AC) Vents with excessive dust in Catheterization Ward j) Acoustic tiles in general were observed with water stains and humidity. k) Broken Formica on nurses’ counters in the ER l) Air Conditioning (AC) Vents with excessive dust in ER waiting area m) Pager system was found to be with low volume in areas. 51782 9. During the emergency room tour performed on 12/09/2025 through 12/10/2025 from 9:00 AM till 2:00 PM accompanied by the emergency room manager (employee #39) and quality coordinator (employee #11), the following was observed: a) Peeling paint is observed in the following areas: - Door frames in medical office areas #1, #2, #3. - Consultation office. - Laboratory room. - Treatment rooms #1 and #2. - Wall in critical area #2 and #8. - Utility door. - Stabilizer unit. b) Walls with cracked tiles and holes are observed in the following areas: - Medicine room. - Column next to the utility room door. c) In the minor surgery area, the following were observed: - Broken Formica door. - Excessive mold in the acoustic cross-section. d) In the Pediatric triage area, the following was observed: - Missing acoustic panels.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (employee #24) and Engineering Director (employee #25), 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 from12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM, for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS2567 form (K221, K222, K223, K225, K281, K291, K293, K321, K323, K342, K343, K353, K355, K363, K371, K712, K761, K781, K902, K904, , K923).”

“LOCATION OF FACILITIES CFR(s): 482.41(c)(1) Diagnostic and therapeutic facilities must be located for the safety of patients. This Standard is not met as evidenced by: 51637 Based on facility Imaging center tour performed from 12/09/2025, it was determined that the facility failed to maintain the diagnosis and treatments areas in a safety condition for patients. Findings include: 1. During the imaging center tour performed on 12/09/2025 from 9:00 AM till 11:00 AM accompanied by the imaging center manager (employee #9), the following was observed: a. The nursing call system was not working in 6 of the bathrooms used by patients. b. No nursing call system was found in 4 of the 4 patient dressing rooms available in the area. 51782 2. During the round made with the Emergency Room Manager (employee #39) and Quality Coordinator ( employee #11) in the emergency room department area on 12/09/2025 at 9:00 AM through 12:00 PM, the following was observed: a) At 10:05 AM portable heater in the pediatric area of the medical office.”

“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: 51637 Based on facility Imaging center, Operating Room and Emergency Department tour performed from 12/09/2025 to 12/11/2025, it was determined that the facility failed to maintain the diagnosis and treatments equipment in optimal conditions. Failed to ensure preventive maintenance of medical equipment and expiration dates of surgical supplies. Findings include: 1. During the Imaging center tour performed on 12/09/2025 from 9:00 AM till 11:00 AM accompanied by the imaging center manager (employee #9), the following was observed: a. An X-ray/CT machine was found with extensive corrosion in the handle areas. b. Storage shelves with extensive corrosion and paint peeling. 2. During the imaging center tour performed on 12/09/2025 from 9:00 AM till 11:00 AM accompanied by the imaging center manager (employee #9), the following was observed: a. X-ray lecture lamps have not been inspected since 2011. b. Sphygmomanometers do not have seals or evidence of inspection. c. Patient scales have not been calibrated or inspected since 2014. 3. During the rehabilitation and outpatient area tour performed on 12/10/2025 from 1:20 PM till 1:45 PM accompanied by the physical therapist (employee #10), the following was observed: a. X-ray lecture lamps have not been inspected since 2013. b. The maintenance of the heat lamp used for treatment expired on 02/2025. 47632 2. During the observations made, the following were found: Pre-anesthesia area: a. On 12/09/2025 at 10:04 AM, two patient warmers were observed without preventive maintenance. b. On 12/09/2025 at 10:06 AM, two cardiac monitors were observed without preventive maintenance. c. On 12/09/2025 at 10:10 AM, nine expired blue citrate tubes were observed in the venipuncture cart (4) on 09/01/2025 and (5) on 08/01/2025, two expired primary plum sets (1) 04/01/2025 and (1) 10/01/2025, and Three blood collection sets #23, expiring 11/30/2025. The Head nurse (employee #16) discarded the expired surgical supply. Operating room: a. On 12/09/2025 at 10:44 AM, 1 out of 4 anesthesia machines were observed without preventive maintenance. b. On 12/10/2025 at 10:17 AM, an 8.0 mm endotracheal tube expired 10/22/2024 was observed in the anesthesia cart. c. 12/10/2025 at 1:30 PM, Five 10-milliliter (ml) syringes expired in 06/2009, and one 60-ml syringe expired in 04/2008 were observed in the malignant hyperthermia cart. The anesthesia supervisor (employee #19) discarded the expired surgical supply. Cardiovascular laboratory: a. On 12/09/2025 at 11:21 AM, it was observed that two D-stat-dry had expired on 11/15/2025 in the presence of the general nurse (employee #17) and the head nurse (employee #16). b. On 12/09/2025 at 11:24 AM, defibrillator was observed without preventive maintenance. c. On 12/09/2025 at 11:35AM, four suction tubing expired on 02/28/2025 and one suction sleeve expired on 09/20/2024 were observed in the anesthesia cart. d. On 12/09/2025 at 1:35 PM, in the cardiovascular laboratory recovery area, four #16 suction catheters expired on 06/15/2024 and two adult manual resuscitator kits expired on 01/23/2025 were observed. The Head nurse (employee #16) discarded the expired surgical supply. Recovery: a. On 12/09/2025 at 11:24 AM, 6 out of 6 cardio monitors were observed without preventive maintenance. 5, Delivery a. On 12/11/2025 at 9:35 AM, an infusion machine was observed without preventive maintenance. b. On 12/11/2025 at 9:45 AM, it was observed that four of the four delivery rooms, as well as one cesarean section room, lacked preventive maintenance on pediatric scales. c. On 12/11/2025 at 9:55 AM, an expired surgical gown with an expiration date of 11/01/2025 was observed. d. On 12/11/2025 at 10:08 AM, in the storage area of the delivery room, seven sets of primary blood expired on January 12, 2025, and thirty-five 1 ml insulin syringes expired on October 8, 2025, were observed. The surgical supplies were removed by the head labor and delivery nurse (employee #22). e. On 12/11/2025 at 10:40AM, two sterile gloves, size 6 1/2, with an expiration date of 10/05/2025, and one size 7 1/2, with an expiration date of 09/30/2025, were observed in the high-risk area. f. On 12/11/2025 at 11:07 AM, three expired primary blood sets were observed: (1) 02/01/2025, and (2) 03/01/2024 in the recovery area. The Head nurse (employee #16) discarded the expired surgical supply. 51782 Facility policy provided by Emergency Room Manager (employee #39), on 12/10/2025 at 91:16 PM was reviewed. The policy was reviewed in December 2024, “Uso del (Nurse Call)” Use of Nurse Call . The policy states on page 1, section 2 that the nurse call system is a mechanism that allows the patient to request help from nursing staff using a button or device accessible from the bed, bathroom, or other assigned areas. 3. During the round made with the Emergency Room Manager (employee #39) and Quality Coordinator (employee #11) in the emergency room department performed on 12/09/2025 through 12/10/2025 at 9:00 AM through 2:00 PM, the following was observed: a) The nurse call cable was not accessible to the patient in the following rooms (critical area #3, #4, #5, #6, #7 and #8), which compromised patient safety. 4. Nursing counter with broken Formica. 5. In the pediatric ward, the following was observed: - Mold on the side rails of stretchers in rooms #3, #4, and #5. - Torn vinyl upholstery on chairs in rooms #1, #5, and #6. 6. In the adult respiratory therapy area, the following was observed: - Torn vinyl upholstery on chair.”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 51637 Based on facility Imaging center and Rehabilitation area tour performed from 12/09/2025 to 12/10/2025, it was determined that the facility failed to maintain adequate lighting and ventilation in the treatment’s areas. Findings include: 1.During the Imaging center tour performed on 12/09/2025 from 9:00 AM till 11:00 AM accompanied by the imaging center manager (employee #9), the following was observed: a. One patient’s dressing room had no lighting and the lamp was broken. b. Two treatment rooms had no ventilation window or air inlet. 2. During the Rehabilitation and Outpatient area tour performed on 12/10/2025 from 1:20 PM till 1:45 PM accompanied by the physical therapist (employee #10), the following was observed: a. There was insufficient lighting in the hallway in front of the treatment cubicles due to a damaged lamp.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47632 Based on observations made in the Operating Room (OR) with head nurse (employee #16) and anesthesia supervisor (employee #19) on 10/12/2025 at 9:10AM, it was determined that the facility did not ensure that OR staff washed their hands after removing gloves. Findings include: The supervisor (employee #19) provided the facility policy, last update on 05/08/2024, “Practica de inyecciones seguras” Safe Injection Practice on 12/11/2025 at 1;30 PM. The policy states on page 1, wash your hands before preparing the medication. Disinfect the rubber seal with alcohol before performing the procedure. 1. During the procedure for patient (RR #29), a 38-year-old female admitted on 12/10/2025 for sterilization, the following was observed: a. Operating room technician staff (employee #20) was observed placing fenestrated surgical drapes on the IV stands as support. b. An anesthesia nurse (employee #18) was observed not washing their hands with soap and water or hand sanitizer before removing intravenous medications. c. An anesthesia nurse (employee #18) was observed not disinfecting the rubber seal of the Nimbex medication. d. The operating room technician (employee# 20) was observed removing her gloves and putting on clean ones without washing her hands with soap and water or using hand sanitizer after completing the procedure.”

“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: 51637 Based on observations performed on 12/09/2025 till 12/12/2025, it was determined that the facility failed to provide adequate infection control monitoring related to isolation rooms for contact precautions, hand washing, soiled linen room, equipment cleaning, Findings include: 1. During the imaging center tour performed on 12/09/2025 from 9:00 AM till 11:00 AM accompanied by the imaging center manager (employee #9), the following was observed: a. Visible dust and dirt were observed on all treatment machines as well as on the floor and around the machines. 47632 2. During observations made in operating rooms 1, 2, 3, and 4, on 12/09/2025 at 10:41 AM, it was noted that a total of 20 out of 20 window operators had rusty and dusty windows. 3. During observation of the entrances to operating rooms 1, 2, 3, and 4, on 12/09/2025 at 10:45 AM, door frames with peeling paint were noted. 4. During observation of the operating rooms 1, 2, 3, and 4, on 12/09/2025 at 10:48 AM, the doors were noted too close completely. The facility failed to maintain a sanitary environment and effective barriers in the operating room are a potential risk for contamination. 51782 5. During the round made with the Emergency Room Manager (employee #39) and Quality Coordinator (employee #11) in the emergency room department area on 12/09/2025 at 9:00 AM through 12:00 PM, the following was observed: a) At 9:14 AM, in the medicine room, the handles of the sink water mixer are corroded and with hardness of the water. b) At 9:38 AM, white cart for placing venous access in patients, with tape stuck on the edge, looking stained and dirty. c) At 10:56 AM, in the central storage room on emergency room department: - One lumbar puncture set expired on 09/01/2025 and two expired on 11/01/2025. - Two thoracic catheter #36 expired on 08/4/2023. - One thoracic catheter #32 expired on 09/22/2023. - One thoracic catheter #28 expired on 06/09/2024. - Two thoracic catheter #20 expired on 09/14/2025. - Two thoracic catheter #24 expired on 10/06/2025. - One blood gas kit expired on 09/2025. 6. During the round made with the Therapy Respiratory Supervisor (employee #43) in the respiratory therapy department area on 12/10/2025 at 9:30 AM through 11:00 AM, the following was observed: a) At 10:07 AM, four bitrac select, full face mask expired on 09/2025 were observed on the medical-surgical supplies area of the respiratory therapy department. 51829 7. On December 12, 2025, at 9:30 a.m., the registered nurse (employee #34) administered Lovenox subcutaneously and recapped the syringe. The CDC, in its statement titled “Centers for Disease Control and Prevention.” United States Department of Health and Human Services. October 4, 2019. Archived from the original on April 10, 2020. Retrieved May 15, 2020, indicates that disease control and prevention, including professionals and their practices in medication administration, prohibits recapping. 8. On November 12, 2025, at 10:55 a.m., during a visit to the chemotherapy administration room, the nursing professional (employee #36) was observed placing unlabeled 0.9% saline syringes on the treatment cart without using a barrier to prevent contamination. The World Health Organization, in its document entitled WHO Technical Report Series No. 957, 2010, outlines guidelines for the safe preparation of medications, including aseptic techniques and labeling, among other things. These guidelines were disregarded following intervention by the quality coordinator (employee #26), who also developed a plan to improve practices in conjunction with the unit manager. 9. During the rounds of the units, the nursing professionals exhibited poor hand hygiene practices and inadequate use of personal protective equipment such as gloves and gowns. Employees in the medical-surgical units, the neonatal ward, and the chemotherapy ward use gloves and, once discarded, do not wash their hands. They enter patient rooms wearing gloves and do not change them for patient interventions. Handwashing time is not within the established timeframe, and they reuse the same gown between babies in the neonatal ward. The hospital’s established Hand Hygiene policy # 3.1 dated 05/27/2022, outlines the correct handwashing and glove use procedures. The unnumbered PPE usage standard, titled “Use of Isolation Gowns in the NICU, Nursery, and Delivery Room,” dated 12/12/2025, states in its procedure that gowns should not be reused between patients.”

“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 observations made in the operating room with the head nurse (employee #16) on 12/10/2025 at 9:20 AM, it was determined that the facility failed to ensure that the timeout was performed immediately before the start of the procedure. Findings include: During the procedure for patient (RR #29), a 38-year-old female admitted on 12/10/2025 for sterilization, the following was observed: 1. The circulating registered nurse (employee #21) took a “Timeout” before the procedure, but the nurse anesthetist (employee #18), operating room technician (employee #20), and surgeon did not interrupt their conversation to identify the patient, confirm the correct procedure, site, side, and check for allergies. The circulating nurse had to perform a “Timeout” a second time, and everyone actively confirmed verbally. The facility failed to ensure, prior to the start of the procedure, the participation and confirmation of the entire team in accordance with the Universal Protocol and AORN guidelines.”

“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 operating room, delivery, and cesarean section room with Head Nurse OR (employee #16), the anesthesia supervisor (employee #19), Head nurse Delivery (employee #22) and maternal and child health manager (employee #23) from 12/09/20250 to 12/12/2025 from 8:00 a.m. to 3:00 PM, it was determined that the facility failed to ensure the inspection and maintenance of biomedical equipment. Findings include: 1. During observations made in the operating room, cardiovascular laboratory, and delivery room, the following were found: Pre-anesthesia area: a. On 12/09/2025 at 10:04 AM, two patient warmers were observed without preventive maintenance. b. On 12/09/2025 at 10:06 AM, two cardiac monitors were observed without preventive maintenance. Operating room: a. On 12/09/2025 at 10:44 AM, 1 out of 4 anesthesia machines were observed without preventive maintenance. Cardiovascular laboratory: a. On 12/09/2025 at 11:24 AM, defibrillator was observed without preventive maintenance. Recovery: a. On 12/09/2025 at 11:24 AM, 6 out of 6 cardio monitors were observed without preventive maintenance. Delivery: a. On 12/11/2025 at 9:35 AM, an infusion machine was observed without preventive maintenance. b. On 12/11/2025 at 9:45 AM, it was observed that four of the four delivery rooms, as well as one cesarean section room, lacked preventive maintenance on pediatric scales.”

“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 observations made in the operating room with the head nurse (employee #16) and anesthesia supervisor (employee #19) from 12/09/2025, to 12/12/2025, it was determined that the facility failed to provide evidence of preventive maintenance of biomedical equipment and lacked custody of anesthesia medications. Findings include: 1. Pre-anesthesia area: a.On 12/09/2025 at 10:04 AM, two patient warmers were observed without preventive maintenance. b. On 12/09/2025 at 10:06 AM, two cardiac monitors were observed without preventive maintenance. 2. Operating room: a. On 12/09/2025 at 10:44 AM, 1 out of 4 anesthesia machines were observed without preventive maintenance. 3. Cardiovascular laboratory: a. On 12/09/2025 at 11:24 AM, defibrillator was observed without preventive maintenance. b. On 12/09/2025 at 11:26 AM, it was observed that the anesthesia cart was open with high-risk medications accessible to unauthorized personnel or patients. 4. Recovery: a. On 12/09/2025 at 11:24 AM, 6 out of 6 cardio monitors were observed without preventive maintenance. 5, Delivery: a. On 12/11/2025 at 9:35 AM, an infusion machine was observed without preventive maintenance. b. On 12/11/2025 at 9:45 AM, it was observed that four of the four delivery rooms, as well as one cesarean section room, lacked preventive maintenance on pediatric scales.”

“STANDARD TAG FOR OUTPATIENT SERVICES CFR(s): 482.54 Standard-level Tag for §482.54 Condition of Participation: Outpatient Services If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice. This Standard is not met as evidenced by: 51637 Based on interviews and documents reviewed performed on 12/10/2025 till 12/11/2025, it was determined that the facility failed in maintaining and updating the policies and procedures of the outpatient services program. Findings include: 1. During the rehabilitation and outpatient area manual of policies and procedure review performed on 12/10/2025 from 1:20 PM till 1:45 PM accompanied by the physical therapist (employee #10), the following was observed: a. The manual has not been evaluated or updated since 2011. 2. In an interview with employee #10 performed on 12/10/2025 at 1:40 PM, she stated that the program does not have a manager since 2022, and the administrative tasks have been neglected since then. 3. In an interview with the director of human resources (employee #12) performed on 12/11/2025 at 9:18 AM she stated that this program has been without manager since 2022, and they have been trying to recruit someone for the position of administrative manager but have been unsuccessful. 4. In an interview with the risk manager (employee #46) performed on 12/11/2025 from 2:00 PM till 2:23 PM she stated that this program does not monitor or report incidents or accidents since 2022. 5. In an interview with the QAPI coordinator (employee #11), performed on 12/11/2025 at 2:30PM she stated that this program has not reported or monitored quality indicators since 2022.”

“ORGANIZATION OF REHABILITATION SERVICES CFR(s): 482.56(a) The organization of the service must be appropriate to the scope of the services offered. This Standard is not met as evidenced by: 51637 Based on interviews and documents review performed on 12/10/2025 till 12/11/2025, it was determined that the facility failed to maintain and update the policies and procedures of the rehabilitation program. Findings include: 1. During the rehabilitation and outpatient area manual of policies and procedure review performed on 12/10/2025 from 1:20 PM till 1:45 PM accompanied by the physical therapist (employee #10), the following was observed: a. The manual has not been evaluated or updated since 2011. 2. In an interview with employee #10 performed on 12/10/2025 at 1:40 PM, she stated that the program does not have a manager since 2022, and the administrative tasks have been neglected since then. 3. In an interview with the director of human resources (employee #12) performed on 12/11/2025 at 9:18 AM she stated that this program has been without manager since 2022, and they have been trying to recruit someone for the position of administrative manager but have been unsuccessful. 4. In an interview with the risk manager (employee #46) performed on 12/11/2025 from 2:00 PM till 2:23 PM she stated that this program does not monitor or report incidents or accidents since 2022. 5. In an interview with the QAPI coordinator (employee #11), performed on 12/11/2025 at 2:30PM she stated that this program has not reported or monitored quality indicators since 2022.”

“RESPIRATORY CARE PERSONNEL POLICIES CFR(s): 482.57(b)(1) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing. This Standard is not met as evidenced by: 51782 Based on the review of documents with the Human Resources Director (employee #12), it was determined that the facility failed to ensure the credentials files (CF) are updated qualification for respiratory therapy personnel for 2 out of 8 CF reviewed (CF #2 and 8). Findings include: 1. During review of eight personnel credential files performed on 12/11/2025 from 1:15 PM through 2:15 PM provided evidence of the following: a) One out of eight credential files were observed with Health certificate expired on 05/28/2025 (C.F #2). b) One out of eight respiratory therapy credential files failed to show evidence of Cardiopulmonary Resuscitation (CPR), (C.F #8). c) One out of eight credential files failed to show updated evidence of Hepatitis Vaccine or titers (C.F #8). d) One out of eight credential files failed to show updated evidence of Influenza Vaccine or the Exoneration form for Influenza Vaccine (C.F #8). e) One out of eight credential files failed to show updated evidence of Chickenpox vaccine or titers (C.F #8). f) One out of eight credential files failed to show updated evidence of Covid 19 vaccine (C.F #8).”

“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 seven medical records reviewed (RR) and policies/procedures with the respiratory therapist supervisor (employee #43), it was determined that the facility failed to ensure that respiratory therapy services orders must be documented in the patient’s medical record in accordance with the requirements for 3 out of 7 records reviewed (R.R. #7, #14 and #58). Findings include: Facility policy provided by Respiratory Therapy Supervisor (employee #43), on 12/10/2025 at 10:45 AM was reviewed. “Política concerniente a las notas de progreso”, Policy concerning progress notes” The policy states on page 1 that every respiratory therapist must fully document the treatments administered in the evolution clinical records. Facility policy provided by Respiratory Therapy Supervisor (employee #43), on 12/11/2025 at 10:05 AM was reviewed. “Asignación de Horario para la administración de los tratamiento.” Assignment of Time for the administration of the treatments” The policy states on page 43 that these schedules must be followed when administering routine treatments that deliver medication via micro nebulization, also known as a power nebulizer. The frequency for treatments every 4 hours is as follows: 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM, 12:00 AM, and 4:00 AM. 1. Records were reviewed from 12/10/2025 to 12/11/2025 from 9:00 AM to 3:45 PM of patients receiving respiratory therapy and provided evidence that respiratory therapists were not documenting the progress notes on all shifts and the frequency of the treatment’s accordance with the medical order for (R.R #7, #14, and #58). 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. Record reviewed (#14, and #58), provided evidence that the respiratory therapists did not follow the frequency of treatments as per medical order. a) R.R #7 is a 62-year-old male who was admitted on 12/05/2025 with a diagnosis of decompensated congestive heart failure. The record reviewed was performed on 12/10/2025 at 10:55 AM, with the respiratory therapist supervisor (employee #43), provided evidence that on 12/07/2025 at 11:30 AM the physician ordered FFT with Atrovent 0.02% / 3ml nss one amp by power nebulizer every four hours and Xopenex 0.63mg / 3ml nss one amp by power nebulizer every four hours. During the record review, it was observed that on 12/09/2025, during the shifts from 7:00 AM to 3:00 PM and 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 #14 is an 81-year-old female who was admitted on 11/29/2025 with a diagnosis of severe hyponatremia, mild dehydration. The record reviewed was performed on 12/10/2025 at 1:50 PM, with the respiratory therapist supervisor (employee #43), provided evidence that on 11/30/2025 at 3:35 PM and 12/03/2025 at 7:20 PM the physician ordered FFT with Atrovent 0.02% / 3ml nss one amp by power nebulizer every four hours and Xopenex 0.63mg / 3ml nss one amp by power nebulizer every four hours. During the record review, it was observed that on 12/02/2025, during the shifts from 7:00 AM to 3:00 PM the respiratory therapy staffs the treatment scheduled for 8:00 AM was not documented in the patient progress note, and the nebulizer treatment administered on 12/03/2025, was documented at 10:00 AM. It was also observed that on 12/03/2025, during the shifts from 11:00 PM to 7:00 AM, the respiratory therapy staff did not document these administrations in the patient’s progress notes. During an interview with the pharmacy department director (employee #45) on 12/11/2025 at 3:30 PM, she stated that the medication Levalbuterol and Ipratropium Bromide for shift 7-3 was dispensed from the Omnicell machine on 12/02/2025, at 9:11 AM. She also stated that on 12/03/2025, the levalbuterol for shift 7-3 was dispensed from the Omnicell machine at 9:21 AM and the ipratropium bromide at 9:22 AM. c) b) R.R #58 is a 72-year-old female who was admitted on 12/09/2025 with a diagnosis of acute bronchospasm. The record reviewed was performed on 12/10/2025 at 1:30 PM, with the respiratory therapist supervisor (employee #43), provided evidence that on 12/09/2025 at 12:10 PM and the physician ordered FFT with Albuterol sulfinh 2.5mg/3ml one amp by power nebulizer per one dose and Atrovent 0.02%/3ml nss one amp by power nebulizer per one dose. During the record review, it was observed that on 12/09/2025, during the shifts from 7:00 AM to 3:00 PM the respiratory therapy staff did not document these administrations in the patient’s progress notes. During an interview with the pharmacy department director (employee #45) on 12/11/2025 at 3:35 PM, she stated that the medication Albuterol Sulfate and Ipratropium Bromide for shift 7-3 was dispensed from the Omnicell machine on 12/09/2025 at 3:28 PM.”

“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 12/12/2025 from 8:00 AM through 11:30 AM, 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 facility patients. Findings include: During the review of the facilities Emergency Preparedness Program with facility Safety Officer (employee #24) on 12/12/2025 at 9:30 AM it was noted that the EP failed to have written 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.”

“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 12/12/2025 from 8:00 AM through 11:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. Findings include: During the review of the facilities Emergency Preparedness Program with facility Safety Officer (employee #24) on 12/12/2025 at 9:50 AM it was noted that the facility failed to inspect and maintain all power generators in the facility.”

“Patient Sleeping Room Doors CFR(s): NFPA 101 Patient Sleeping Room Doors Locks on patient sleeping room doors are not permitted unless the key-locking device that restricts access from the corridor does not restrict egress from the patient room, or the locking arrangement is permitted for patient clinical, security or safety needs in accordance with 18.2.2.2.5 or 19.2.2.2.5. 18.2.2.2, 19.2.2.2, TIA 12-4 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), it was determined that the facility did not ensure to prevent locks on patient sleeping room doors in accordance with 18.2.2.2.5 or 19.2.2.2.5 / 18.2.2.2, 19.2.2.2, TIA 12-4 Findings include: During visual inspection of the second floor Medicine Department at 12/11/2025 at approximately 2:00 PM it was noticed that Patient Room #206 had a thumb lock on the room entrance door. Two additional rooms were observed with thumb lock arrangements but was notified to be interns rooms not patient rooms.”

“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 Based on observations made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24),facility failed to provide exit door leaves equipped with panic hardware or fire exit hardware in the means of egress readily accessible, 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: Observation and interview on 12/11/2025 at approximately 1:30 PM exit door in the Physical Therapy area revealed thumb turn lock on the egress side. The thumb turn lock and fastening device on the door could restrict emergency use of the exit access.”

“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 on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), it was determined that the smoke barrier doors on the Surgery Department and Second floor failed to close flush when released as required by the 2012 edition of the Life Safety Code of the NFPA Section 7.2.1.8.2. Findings include: 1. The smoke barrier doors on the second floor were observed on 12/11/2025 approximately at 10:30 AM did not close flush to its frame, this can permit smoke, fire and noxious gases to enter the smoke compartments in the event of a fire. 2. Double door next to Surgery Room #5 was observed on 12/10/2025 approximately at 11:30 AM, it was found not to close flush to its frame, this can permit smoke, fire and noxious gases to enter the smoke compartments in the event of a fire. 3. Double door on entryway of Surgery Department was observed on 12/09/2025 approximately at 9:00 AM, it was to be blocked by stretcher, this can cause the door not to close properly in the event of a fire alarm activation.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (employee #24) and Engineering Director (employee #25), it was determined that the facility failed to comply with NFPA 101 / 7.2 for Stairways and Smokeproof enclosures. Findings include: During visual obsevation of the facilities interior stairway with the Safety Officer (employee #24) and Engineering Director (employee #25) on 12/09/2025 through 12/12/2025 it was noted that the stairway did not provide special signage within the enclosure at each floor landing in accordance with NFPA 101 / 7.2.”

“Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (employee #24) and Engineering Director (employee #25), the facility failed to provide emergency illumination that would operate automatically along the means of egress and failed to have the required illuminance with two lamps energized during emergencies in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA 101 Sections 19.2.8, 7.8, 7.8.1.1, 7.8.1.2, 7.8.1.4 and 7.9.2.1. Findings include: 1. During the tour for life safety from fire, emergency lighting along means of egress were verified with the facility Safety Officer (Employee #24) and the following was determined: a. Observations on 12/09/2025 through 12/12/2025 revealed that all exit discharges did not have the required illuminance with two lamps energized during emergencies for all emergency exit.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), it was determined that the facility failed to have emergency lighting in accordance with 7.9, 18.2.9.1, 19.2.9.1. Findings include: 1. Emergency light on Operation Room #1 was observed blinking. 2. Emergency lights (2) on Operation Room #3 were found inoperable. 3. Emergency light on Operation Room #4 was found inoperable. 4. Only one emergency light was observed on Surgery Department main hallway to cover approximately 45 feet of space. This one lamp does not provide the minimum one (1) lumen required for the totality of the area.”

“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 on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), it was determined that the facility failed to provide exit and directional signs displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 Findings include: 1. No exit signs was observed in front of exit double door next to C Section room. 2. Relocation of exit sign located station #6 and warehouse “Almacen A” in Catheterization area is required in order to be visible from all directions. 3. Exit sign located station #5 of recovery arae of LSI is visible from one side, should be visible from both sides in order to be visible from all directions. 4. No exit sign was observed in front of the door and station #1 in LSI. 5. Exit sign in Critical Care area of Emergency Ward (ER) located in from of cubicule #8 close to nurses station was not visible from all areas. 6. A curtain was observed in the passageway between Critical Care unit and Observation Unit of the ER impeding the clear view of an exit sign. 7. No exit sign was observed in the Pharmacy Department, at least 5 signs are needed to state obvious exit routs. 8. Exit sign in Medical Record office area was not visible from all areas and a extra exit sign shoul be placed in the hallway. 9. Exit sign in front of main entrance door and waiting area should be relocated in order to be visible from all areas in the Computed Tomography (CT) area. 10. Exit sign in hallway of CT rooms, Magnetic Resonance Imaging (MRI) room and exit shoul be relocated in order to be visible from all areas. 11. No exit sign was observed in the MRI and old CT area. 12. No exit sign was observed in the MRI and new CT area. 13. Minimal visibility was noticed on exit sing located between cubicles #4 and #5 on Pedriatric ER. 14. Exit signs on Medical Record area should be relocated in order to be visible, additional sing should be installed in hallway.”

“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 on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), faclity failed to ensure 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. Findings include: 1. During visual observation of the Autoclave area on the Surgery next to Operating Room #4, it was noticed that fire wall was not constructed top to bottom, some penetrations were observed leaving space on the plenum. 2. During visual observation of the Mechanical Room on the CT area hallway, it was noticed that some penetrations were existed leaving space on the plenum.”

“Anesthetizing Locations CFR(s): NFPA 101 Anesthetizing Locations Areas designated for administration of general anesthesia (i.e., inhalation anesthetics) are in accordance with 8.7 and NFPA 99. Zone valves are: located immediately outside each life-support, critical care and anesthetizing location of moderate sedation, deep sedation, or general anesthesia for medical gas or vacuum; readily accessible in an emergency; and arranged so shutting off any one anesthetizing location will not affect others. Area alarm panels are provided to monitor all medical gas, medical-surgical vacuum, and piped WAGD systems. Panels are at locations that provide for surveillance, indicate medical gas pressure decreases of 20 percent and vacuum decreases of 12 inch gauge HgV, and provide visual and audible indication. Alarm sensors are installed either on the source side of individual room zone valve box assemblies or on the patient/use side of each of the individual zone box valve assemblies. The EES critical branch supplies power for task illumination, fixed equipment, select receptacles, and select power circuits, and EES equipment system supplies power to ventilation system. Heating, cooling, and ventilation are in accordance with ASHRAE 170. Medical supply and equipment manufacturer’s instructions for use are considered before reducing humidity levels to those allowed by ASHRAE, per S&C 13-58. 19.3.2.3 (LSC) 5.1.4.8.7, 5.1.4.8.7.2, 5.1.9.3, 5.1.9.3.4, 6.4.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), it was determined that the facility failed to identify and ensure free acces to emergengy shutt-off valves for medical gases. Findings include: On 12/09/2025 approximately at 9:30 AM it was observed that all (7) zone valves on the Surgery Department were not identified as emergency shut-off valves.”

“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 on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), it was determined that the facility failed to maintain initiation devices in all areas and in optimal condition. Findings include: 1. On 12/09/2025, approximately at 8:47 AM, no smoke detector was observed bathroom area of Delivery Room #2. 2. On 12/09/2025, approximately at 10 :45 AM, no smoke detector was observed on the Sonography Area. 3. On 12/10/2025, approximately at 9:10 AM, smoke detectors MI 120 and MI 120 located on Pediatric Emergency Ward were found un operational. 4. On 12/10/2025, approximately at 10:10 AM, exesive dust and black stains were observed on smoke detector vents in the EKG area. 5. On 12/11/2025, approximately at 9:30 AM, smoke detector MI 190 located on the CT Scan area was found un operational. 6. On 12/11/2025, approximately at 9:30 AM, smoke detector on the mechanical room on the CT Scan area hallway was observed un attached from ceiling. 7. On 12/11/2025, approximately at 10:30 AM, no smoke detector found on X ray room on the ER.”

“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 observation and interview, 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 performed form 12/09/2025 through 12/12/2025 revealed that there are no visual (strobe) or audible signals in public area bathrooms.”

“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 on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), the facility failed to comply with Life Safety Code 2012 Edition, Section 9.7.5, 9.7.7, 9.7.8, NFPA 25, 2011 Edition 13.2.7.2. Findings include: Observation and interview on 12/10/2025, at approximately 2:30 PM revealed main sprinkler riser and sprinkler gauge was not dated. No documentation available for the five-year calibration report for this gauges.”

“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 on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25) ,it was determined that 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 12/09/2025 approximately at 9:10 AM it was noticed that a ABC fire extinguisher next to Operating Room #1 was bloqued by Medical Equipment. 2. On 12/09/2025 approximately at 9:40 AM it was noticed that a ABC fire extinguisher on the Surgery Ward were bloqued or obstructed by Medical Equipment. 3. On 12/10/2025 approximately at 9:00 AM it was noticed that two (2) Type K fire extinguisher on the kitchen area did not have the monthly inspection.”

“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 on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (employee #24) and Engineering Director (employee #25), 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 12/09/2025 through 12/12/2025 from 8:30 AM through 4:00 PM, patient’s sleeping room doors were tested it was found that roomsdo 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 Medicine: #201, #202, #211,#212, #214, #215, #216, #218, #219 #222,#224, #225, #226, #228, #229, #230, #231, #232, #233, #234, #235, #236 Third Floor Medicine: #301, #303, #306, #307, #308, #311, #312, #313, #313, #314, #315, #316, #317, #319, #320, #321, #325, #327, #328, #330, #335 The finding was verified by the Safety Officer at the time of the observation.”

“Subdivision of Building Spaces - Smoke Compar CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Compartments 2012 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier. 19.3.7.1, 19.3.7.2 Detail in REMARKS zone dimensions including length of zones and dead-end corridors. This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), the facility failed to comply with Life Safety Code 2012 Edition, Section 19.3.7.3, 8.6.7.1(1) . Findings include: Observation and interview on 12/09/2025 through 12/12/2025 revealed that smoke barrier doors in floors #2 and #3 had penetrations.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 47384 Based on record review and interview made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24), it was noticed that facility failed to hold Fire drills at expected and unexpected times under varying conditions. Findings include: During review of the Fire Drill documentation it was observed that no driils were performed during hours of 2:00 PM through 6:00 AM.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), it was determined that the facility failed to ensure fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (2010 NFPA 80). Findings include: 1. No written records of inspection and testing are maintained and are available for review at the moment of the survey. 2. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, were not routinely inspected as part of the facility maintenance program.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), it was determined that the facility failed to maintain areas free of portable space heating devices. 18.7.8, 19.7.8 Findings include: 1. Two Portable heaters was obseverd on Social Work Department. 2. Portable heater was obseverd on Doctors office in the Pediatric Department.”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (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 the gas and vacuum systems are in optimal conditions as part of a maintenance program and include the required elements. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) Findings include: 1. Facility provided Annual report “ Medical Gases Annual Verification” report performed by external provider on March 2025. This report indicates that: a. One of Two Medical Gas Alarm System ( Engeneering Dept.) is out of service not complying with NFPA 99 ( 5.1.9.2 AND 5.1.9.2.1) . b. The Medical Air compressor do not have master alarm signals conected to master control, does not comply with NFPA 99 ( 5.1.11.2.3). c. During inspection of the Hospital Suction System, it was found that it does not include some components required by the code, such as pressure switch on the main line. d. Emergency Oxygen Connection (EOSC) was not located in an accessible area for use during an emergency as required in NFPA 99 (5.1.3.5.15.1) e. Multiple Valve Boxes did not comply with Code requirements. f. Multiple alarms are obsolete. g. At the moment of the inspection inlets and outlets presented leaks. At the moment of the survey the facility has not corrected issues identified on the inspection performed. The finding was verified by the Safety Officer and Engineering Director.”

“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 made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #24) and Engineering Director (employee #25), 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: A pattern of non labeling the Medical Gas outputs was observed throughout the facility. The finding was verified by the Safety Officer and Engineering Director”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 12/09/2025 through 12/12/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (employee #24) and Engineering Director (employee #25), 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: On 08/20/2025 approximately at 2:30 PM at the cylinder yard the following was observed: 1. Empty and full tanks were observed not fastened with chain. 2. The medical gas cylinder area was observed to be without a roof to protect cylinders for weather.”