Hospital Damas Inc.

“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: 20423 Based on records reviewed (R.R), it was determined that the facility failed to ensure that the hospital inform to the patient or the patient’s representative of the patient’s rights, and provided the standardized notice, “An Important Message from Medicare” (IM), within 2 days of admission for 6 out of 8 records reviewed (R.R #21, #40, #41, #44, #45, and #50). Findings include: The facility failed to inform and provided the standardized notice, “An Important Message from Medicare” (IM), within 2 days of admission, reviewed on 08/27/2024 through 08/28/2024 from 9:30 AM till 3:30 PM: 1. R.R #40 is a 65-year-old male who was admitted on 08/22/2024 with a diagnosis of Bronchopneumonia. During the record review performed on 08/27/2024 at 9:15 AM provide evidence that on 08/22/2024 at admission, the standardized notice was not provided , “An Important Message from Medicare” (IM), within 2 days of admission, the notification was in blank without patient or relative signature.”

“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: 20423 Based on records reviewed (R.R), advance directive policy and procedure, it was determined that the facility failed to ensure that patients or their representatives formulate advance directive and comply with these directives related to mark if patient have or not have advance directive in the Advance Directive orientation for 6 out of 8 records reviewed (R.R #21, #40, #41, #44, #45, and #50). Findings include: The facility failed to mark if patient has or not have advance directive in the Evidence of patient orientation on Advance Directives declaration sheet, reviewed on 08/27/2024 through 08/28/2024 from 9:30 AM till 3:30 PM: 1. R.R #21 is an 86-year-old female who was admitted on 08/17/2024 with a diagnosis of Pneumonia. During the record review performed on 08/28/2024 at 11:02 AM provide evidence that on 08/17/2024 at the admission the patient or relative sign the evidence of patient orientation on Advance Directives declaration sheet and did not mark if have or not have advance directive. 2. R.R #40 is a 65-year-old male who was admitted on 08/22/2024 with a diagnosis of Bronchopneumonia (BKP). During the record review performed on 08/27/2024 at 9:15 AM provide evidence that on 08/22/2024 at the admission the patient or relative did not sign the Evidence of patient orientation on Advance Directives declaration sheet and did not mark if have or not have advance directive. 3. R.R #41 is a 62-year-old male who was admitted on 08/26/2024 with a diagnosis of Gastrointestinal Hemorrhage. During the record review performed on 08/27/2024 at 2:12 PM provide evidence that on 08/25/2024 at the admission the patient or relative sign the evidence of patient orientation on Advance Directives declaration sheet and did not mark if have or not have advance directive. 4. R.R #44 is a 69-year-old female who was admitted on 08/26/2024 with a diagnosis of Herpes Zoster. During the record review performed on 08/28/2024 at 10:19 AM provide evidence that on 08/26/2024 at the admission the patient or relative sign the evidence of patient orientation on Advance Directives declaration sheet and did not mark if have or not have advance directive. 5. R.R #45 is an 87-year-old female who was admitted on 08/27/2024 with a diagnosis of Pneumonitis. During the record review performed on 08/26/2024 at 10:41 AM provide evidence that on 08/26/2024 at the admission the patient or relative sign the evidence of patient orientation on Advance Directives declaration sheet and did not mark if have or not have advance directive. 6. R.R #50 is a 48-year-old male who was admitted on 08/25/2024 with a diagnosis of Covid 19 and Chronic Obstructive Pulmonary Disease (COPD). During the record review performed on 08/27/2024 at 1:44 PM provide evidence that on 08/24/2024 at the admission the patient or relative sign the evidence of patient orientation on Advance Directives declaration sheet and did not mark if have or not have advance directive.”

“PATIENT RIGHTS: INTERNAL DEATH REPORTING LOG CFR(s): 418.13(g)(2), (3)(ii), (4) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (2) When no seclusion has been used and when the only restraints used on the patient are those applied exclusively to the patient’s wrist(s), and which are composed solely of soft, non-rigid, cloth-like materials, the hospital staff must record in an internal log or other system, the following information: (i) Any death that occurs while a patient is in such restraints. (ii) Any death that occurs within 24 hours after a patient has been removed from such restraints. (3) [The staff must document in the patient’s medical record the date and time the death was:] (i) Recorded in the internal log or other system for deaths described in paragraph (g)(2) of this section. (4) For deaths described in paragraph (g)(2) of this section, entries into the log or other system must be documented as follows: (i) Each entry must be made not later than seven days after the date of death of the patient. (ii) Each entry must document the patient’s name, date of birth, date of death, name of attending physician or other licensed practitioner who is responsible for the care of the patient medical record number, and primary diagnosis(es). (iii) The information must be made available in either written or electronic form to CMS immediately upon request. This Standard is not met as evidenced by: 20423 Based on two records reviewed for restraint compliance, with the medical record director employee #36, it was determined that the facility failed to ensure that any death that occurs while patient is restraint or death that occur withing 24 hour after been removed from restraint be recorded in an internal log no later than seven days after the day of deaths and be available at request by CMS for 1 out of 2 restraint record review (RR). RR #48 Finding include: 1. On 9/27/2024 at 9:00 AM during the entrance conference it was answer to the Nurse Director (DON) employee #36 if have any patient that death restraint or after 24 hours to be release of restraint in the last years? The employee #36 states that no death restraint occurred. 2. RR #48 is a 66-year-old female, admitted on 07/02/2024 with a diagnosis of Diabetes Mellitus with Ketoacidosis and Covid 19. During the record review performed on 08/29/2024 at 3:30 PM with the Medical Recor director employee #36 provide evidence of the following: a. The physician ordered on 07/02/2024 at 5:00 PM restraint order per 24 hours with soft limb, in the superior extremities Left and Right to maintain therapeutic environment and to prevent patient from removing vital equipment due to patient don’t follow instruction and security. b. On 07/02/2024 at 9:09 PM the Registered Nurse documented in the Restricted patient report, that patient have restraint in Left and right superior extremities with soft limb due to treatment interruption and patient security, behavior: agitated and disoriented, does not follow instructions, on 07/02/2024 at 5:00 PM, at 6:00 PM, at 8:00 PM and at 10:00 PM. c. On 07/02/2024 at 9:10 PM the RN documented the Alternative nursing measures to avoid restraint: Conduct: Patient attempts to remove medical equipment, intravenous access lines. Alternative measures: provide guidance to the patient’s family. Keep bell accessible, bed low and overhead rails raised, provide prompt assistance, provide comfort and relief from environmental factors, properly secure medical equipment. Effectiveness: Disoriented patients do not follow instructions with attempts to remove intravenous access and nasal cannula. Upper extremities are gently restrained for safety of treatment. c. On 07/02/2024 at 11:21 PM the RN documented the Reassessment of patient condition and intervention. Restriction: Patient restricted see report sheet. d. On 07/02/2024 at 11:29 PM the Registered Nurse documented in the Restricted patient report, that patient have restraint in Left and right superior extremities with soft limb due to treatment interruption and patient security, behavior: agitated and disoriented, does not follow instructions, on 07/03/2024 at 12:00 AM, at 2:00 AM, at 4:00 AM, and at 6:00 AM. e. On 07/03/2024 at 12:19 PM the Physician Green Code Report documented: Green code was called by nursing staff at 12:17 PM because patient was unresponsive to verbal and tactile stimuli. Upon arrival to the patient room was unresponsive without pulse or spontaneous breathing. Immediate Cardio Pulmonary Resuscitation (CPR) maneuvers, external chest compression and ambu bag ventilation was started following Advanced Cardiovascular Life Support (SCLS) protocol, seven doses of Epinephrine 1 milligram (mg) Intravenous (IV) Push per three minutes apart. Dextrose test (Dxt) :365 mg/deciliters (dl). No pulse was restored during the ACLS, electrical activities visible due to Implantable Cardioverter Defibrillators (ICD) patient without palpable pulse, corneal reflex and dilated pupils. The patient was declared dead at 12:44 PM. Attending and family members were notified. f. No evidence was found of RN documentation for the 7-3 shift of 07/03/2024 from 7:00 AM through 1:00 PM. g. No evidence was found related to the Restricted patient report for 07/03/2024 at 8:00 AM,10:0 AM, and 12:00 PM. h. No evidence was found that the nurse documented if release or not the patient from restraint during the green code. i. No evidence was found related to the death note. j. No evidence was found that this restraint death was report and put on the internal restraint death log for the facility.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 15884 Based on ten medical recorded reviewed with the Director of Nursing (DON) (employee #1), it was determined that the facility failed to ensure that the nursing staff develops, and keeps current, nursing care plans for each patient for 3 out of 10 medical records reviewed with respect to the nursing plan of care component. (RR #4, RR #5 and RR#9). Findings include: 1. R.R #4 is a 69-year-old male admitted on 08/21/24 with a diagnosis of Pressure Ulcer on left heel and Diabetes. During the review of the medical record performed on 08/27/24 at 10:30 AM with the Director of Nursing (employee #1) it was identified that plan of care initiated by nursing personnel for the integumentary system and Diabetes when patient was admitted was not individualized. Nursing personnel who initiated and perform revision of the plan of care for the integumentary system and Diabetes do not individualize the patient goals and interventions as part of the patient’s nursing care assessment and re-assessment. Nursing care needs and patient response to nursing interventions was not found included as part of the nurse’s progress notes dated 08/22/24, 08/23/24,08/24/24,08/25/24 and 08/26/24 when it was documented on the plan of care that it was revised. 2. R.R #5 is a 61-year-old male admitted on 08/22/24 with a diagnosis of Hypoxemia, Anemia and had history of End Stage Renal Disease. During the review of the medical record performed on 08/28/24 at 10:00 AM with the Director of Nursing (employee #1) it was identified in the plan of care initiated by nursing personnel for the Cardiovascular system alteration when patient was admitted was not individualized. Nursing personnel who initiated and perform revision of the plan of care for the Cardiovascular system does not individualize the patient goals and interventions as part of the patient’s nursing care assessment and re-assessment. It was documented by nursing personnel that this plan of care was revised on 08/23/24,08/24/24,08/25/24,08/26/24 and 08/27/24, however nursing care needs and patient response to nursing interventions was not found included as part of the nurses’ progress notes on these same dates. Review of the medical record evidenced that this patient was admitted with a recent reconstruction of a vascular access on left arm. A plan of care was initiated on 08/22/24 when patient was admitted for integumentary system alteration. Accordingly with information provided by the Director of Nursing (employee #1) 08/28/24 at 10:20 AM this plan of care was initiated to address patient needs related with the vascular access. However, this plan of care was not individualized for the patient goals and interventions as part of the patient’s nursing care assessment and re-assessment. 3.R.R #9 is a 72 year old female admitted on 08/26/24 with a diagnosis of End Stage Renal Disease Di Novo and Congestive Heart Failure. During the review of the medical record performed on 08/28/24 at 10:50 AM with the Director of Nursing (employee #1) it was identified in the plan of care initiated by nursing personnel for the Cardiovascular system alteration when patient was admitted it was indicated that patient is going to be monitored by telemetry system and that Electrocardiogram is going to be taken every 8 hours. While the case was discussed by nurse in charge of the patient (employee #10) on 08/28/24 at 10:50 AM she was asked if the patient has been on telemetry since admission and she stated that patient has not been in telemetry. Another plan of care was initiated by nursing personnel for Congestive Heart Failure on 08/27/24, in the plan of action stated that vital signs were going to be monitored every 1-2 hours, while the case was discussed by nurse in charge of the patient (employee #10) on 08/28/24 at 10:59 am she was asked if this patient had order to monitor vital signs every 1-2 hours and she stated that vital signs to this patient was taken every 8 hours in every shift. Facility failed to maintain a nursing plan of care that include appropriate patient’s nursing care assessment and re-assessment related with nursing care needs. During review of the facility policy for the plan of care with the Director of Nursing (employee #1) on 08/28/24 at 2:00 PM she stated that facility policy establish that the nursing care plan was part of a larger, coordinated interdisciplinary plan of care. This to promote communication among disciplines and reinforce an integrated, multi-faceted approach to a patient’s care, resulting in better patient outcomes. She stated that nurses who intervene with the patient has the responsibility to individualize the standardized plan of care or modified its contents based on the assessment and re-assessment related with nursing care needs performed on every shift.”

“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: 47632 Based on the review of eighteen closed records reviewed (R.R.) and thirteen active record review during the survey process on 08/27/2024 through 08/29/2024, it was determined that the facility failed to ensure that the clinical records have documentation related to nurse documentation, physician documentation of date and time and complete discharge summary for 18 out of 31 records reviewed (R.R. #4, #5, #22, #23, #25, #26, #27, #29, #31, #33, #40, #41, #43, #44, #45,#46, #49 and #50). Findings include: 1. During the review of the six records reviewed with Compliance Officer (employee #33) and Operations Room Manager (employee #29), the following was found: a. RR #22 is a 48-year-old female admitted on 05/10/2024 with procedure Right Shoulder Arthroscopy. On 08/29/2024 at 12:50 PM, it was observed in the clinical record that the nursing staff did not make the call between twenty-four to forty-eight hours later, the call was made ten days later (05/20/2024). b. R.R #23 is a 55-year-old female admitted on 03/13/2024 with procedure release bilateral breast rupture implant. On 08/29/2024 at 11:35 AM, in the clinical record, a blank discharge summary sheet, date of admission and date of discharge was observed. They also did not make a follow-up call between twenty-four and forty-eight hours. c. R.R #25 is a 47-year-old male admitted on 06/11/2024 with procedure Peripheral Nerves and Plexi, Percutaneous Approach. On 08/29/2024 at 1:01 PM, in the clinical record, a blank discharge summary sheet, date of admission and date of discharge was observed. Additionally, the patient’s arrival time on the PACU sheet was blank. d. R.R #26 is a 47-year-old male admitted on 12/021/2024 with procedure introduction of anesthetic agent into spinal canal. On 08/29/2024 at 1:09 PM, in the clinical record, a blank discharge summary sheet, date of admission and date of discharge was observed. e. R. R #27 is an 83-year-old female admitted on 08/13/2024 with procedure Removal of Synthetic Sub. from right breast. On 08/29/2024 at 1:14 PM, in the clinical record, a blank discharge summary sheet, date of admission and date of discharge was observed. They also did not make a follow-up call between twenty-four and forty-eight hours. f. R.R #29 is a 74-year-old female admitted on 06/23/2024 with procedure total Vaginal Hysterectomy. On 08/28/2024 at 9:11 AM, it was observed in the clinical record that the preoperative nursing estimate sheet did not have the date and time of arrival at the Holding area. g. R.R #31 is a 61-year-old male admitted on 01/23/2023 with procedure Laparoscopic Sleeve Gastrectomy with Hiatal Hernia repair. On 08/28/2024 at 10:01 AM, it was observed in the clinical record that the patient’s consent form for a surgical intervention or medical procedure that the physician entered the incorrect date. h. R.R #33 is a 70-year-old female admitted on 04/18/2023 with procedure replacement of Right Knee Joint Synthetic. On 08/28/2024 at 10:30 AM, the patient’s consent form for surgical intervention or medical procedure, the date and time after the physician signature, and noted that the discharge summary sheet was not completed by the physician. 20423 2. During the review of the thirteen active records reviewed with Epidemiologist Nurse employee #38, Respiratory Therapist Coordinator employee #37, and Medical Record Director employee #36, the following was found: a. R.R #4 is a 69-year-old male who was admitted on 08/21/2024 with a diagnosis of Infected Ulcer. During the record review performed on 08/27/2024 at 10:37 PM with Epidemiologist Nurse employee #38, provide evidence that the plan of care for ulcer was not individualized according to patient needs. On 08/25/204 The physician ordered Place patient in Contact Isolation; However, no evidence was found in the Nurses progress note the patient and relative orientation related to Contact isolation precaution. b. R.R #5 is a 61-year-old male who was admitted on 08/22/2024 with a diagnosis of Hypoxia and Anemia. During the record review performed on 08/28/2024 at 2:39 PM with Respiratory Therapist coordinator employee #37, provide evidence that the physician ordered on 08/22/2024 at 6:00 AM Atrovent 2.5% by power nebulizer (PN) every 4 hour and a Ventury (VM) at 35%, however on 08/24/2024 at 8:00 AM and at 12:00 PM no evidence was found in the medication Kardex that the respiratory therapist administered the therapy. On 08/24/2024 at 8:25 pm the respiratory therapist documented in their note that patient have a VM at 40%, however no evidence was found that the physician increases the VM. and at 11:30 PM no evidence was found the treatment documentation. On 08/27/2024 at 12:25 AM the respiratory therapist documented that patient has a nasal canula at 3 litter per minute, no evidence was found that the physician ordered the change from VM to canula. On 08/26/2024 at 9:00 PM the physician ordered place the VM 35% with Humidifier, however the respiratory therapist did not document the use of humidifier on 08/27/2024 at 3:50 PM, and on 08/28/2024 at 12:10 AM. b. R.R #40 is a 65-year-old male who was admitted on 08/22/2024 with a diagnosis of Bronchopneumonia. During the record review performed on 08/27/2024 at 09:15 AM with Epidemiologist Nurse employee #38, provide evidence that then Treatment and Hospital Consent, Authorization of admitted cases, Orientation Advance Directives and “An Important Message from Medicare” (IM), within 2 days of admission, was in blank without patient or relative signature. Physician order performed on 08/22/2024 at 3:01 PM the sign however did not put the date and hour that sign. c. R.R #41 is a 62-year-old male who was admitted on 08/26/2024 with a diagnosis of Gastrointestinal hemorrhage. During the record review performed on 08/27/2024 at 2:12 PM with Epidemiologist Nurse employee #38, provide evidence that the Evidence of patient guidance on advance directives (advance directives) sheet, did not indicate whether the patient has or does not have advance directives. d. R.R #43 is an 82-year-old male who was admitted on 08/20/2024 with a diagnosis of Multiple Infected Decubit Ulcer and Diabetes Mellitus (DM). During the record review performed on 08/27/2024 at 3:17 PM with Epidemiologist Nurse employee #38, provide evidence that the patient was restraint since 08/27/2024 at 12:00 PM, however no evidence was found in the nurse’s progress note the patient or relative orientation related to restraint, no evidence was found that the registered nurse activates restrain plan of care. e. R.R #44 is a 69-year-old female who was admitted on 08/26/2024 with a diagnosis of Herpes Zoster. During the record review performed on 08/28/2024 at 10:19 AM with Epidemiologist Nurse employee #38, provide evidence that the physician ordered on 08/26/2024 at 8:35 PM admit patient o isolation due to Herpes Zoster, however the physician lack to place type of isolation. The Evidence of patient guidance on advance directives (advance directives) sheet, did not indicate whether the patient has or does not have advance directives. f. R.R #45 is an 87-year-old female who was admitted on 08/27/2024 with a diagnosis of Pneumonitis. During the record review performed on 08/28/2024 at 10:41 AM with Epidemiologist Nurse employee #38, provide evidence that the Evidence of patient guidance on advance directives (advance directives) sheet, did not indicate whether the patient has or does not have advance directives at admission. Then on 08/27/2024 at 12:16 PM the physician ordered Do Not Resuscitate (DNR) patient daughter was oriented by the physician related to DNR, however no evidence was found that the registered Nurse activate the DNR Plan of Care. g. R.R #46 is a 73-year-old female who was admitted on 08/16/2024 with a diagnosis of Sepsis. During the record review performed on 08/28/2024 at 3:13 PM with Respiratory Therapist coordinator employee #37, provide evidence that the physician ordered on 08/16/2024 at 3:20 PM a Non-Rebreathing mask, on 08/20/2024 at 11:10 AM VM at 55% and on 08/25/2024 at 6:30 PM VM %0% humidifier. No evidence was found that on 08/16/2024 at 6:00 PM the respiratory therapist performed the initial evaluation to the patient. No evidence was found on 08/24/2024 at the respiratory therapist documented. No evidence was found on 08/25/2024 at 6:30 PM, on 08/26/2024 at 3:10 PM, on 08/27/2024 at 8:40 AM and 08/28/2024 at 8:43 AM the respiratory therapist documented that the VM was place with humidifier. h. R.R #49 is an 83-year-old female who was admitted on 08/22/2024 with a diagnosis of Acute Appendicitis. During the record review performed on 08/28/2024 at 3:40 PM with Respiratory Therapist coordinator employee #37, provide evidence that the physician performed a telephonic order on 08/24/2024 at 10:15 AM for Spirometry every 2 hour per one, however a on 08/28/24 at 3:40 pm the physician did not counter sign the order. No evidence was found that the respiratory therapist performed the initial evaluation to the patient. i. R.R #50 is a 48-year-old male who was admitted on 08/25/2024 with a diagnosis of Covid and Congestive Obstructive Pulmonary Disease (COPD). During the record review performed on 08/27/2024 at 1:44 PM with Epidemiologist Nurse employee #38, provide evidence that the Evidence of patient guidance on advance directives (advance directives) sheet, did not indicate whether the patient has or does not have advance directives. On 08/25/2024 at 7:03 AM the physician lacks to order that Droplet isolation.”

“CONTENT OF RECORD: DISCHARGE SUMMARY CFR(s): 482.24(c)(4)(vii) [All records must document the following, as appropriate:] Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care. This Standard is not met as evidenced by: 47632 Based on the review of eighteen closed records reviewed (R.R) during the survey process on 08/27/2024 through 08/29/2024, it determined that the facility failed to ensure that the clinical record must contain a summary of the discharge. A discharge summary analyzes the outcome of hospitalization, the patient’s disposition, and the dispositions for follow-up care for 1 out of 18 records reviwed (R.R #33). Findings include: 1. R.R #33 is a 70-year-old female admitted on 04/18/2023 with procedure replacement of Right Knee Joint Synthetic. On 08/28/2024 at 10:30 AM, when evaluating the clinical record, it was observed that the discharge summary sheet was not completed by the physician.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 15884 Based on the observational tour of the facility’s kitchen that prepares the patient’s meals, review of menus, policies/procedures and interview, it was determined that the facility failed to maintain equipment in good condition and keep kitchen premises free of equipment that is not in operation. Findings include: 1. The following was found during the observational tour of the kitchen service with and kitchen supervisor (employee #3) of the hospital on 08/27/2024 from 9:00 AM till 10:30 AM: a. A commercial blender team brand Hobart located in the production area was observed with peeled paint and in need of maintenance. b. A microwave oven that is damaged was observed in the floor in the room located near the enteral feeding room. kitchen supervisor (employee #3) stated on interview on 08/27/2024 at 9:20 AM that this microwave is waiting to be discarded. c. Stainless steel low high table located on the production area was observed with corroded areas in the second shelve..”

“QUALIFIED DIETITIAN CFR(s): 482.28(a)(2) There must be a qualified dietitian, full-time, part-time, or on a consultant basis. This Standard is not met as evidenced by: 15884 Based on five medical records reviewed (R.R), policies/procedures and interview, it was determined that the facility failed to ensure that patient’s nutritional needs are addressed according with professional standards of practice and facility policies for 2 out of 5 records reviewed while evaluating the supervision of the nutritional aspects of patient care (R.R #14 and RR#16). Findings include: Upon review of the facility’s policy for an early assessment and intervention of cases with nutritional risk last update in August 2022, Policy stated on the procedures that is going to be the responsibility of the medical staff, nursing personnel the pharmacist and clinical dietitian to identify patients that could be at nutritional risk. This due to their diagnosis, treatment or other criteria established by the facility nutritional department to be assessed. Policy also stated that early assessment to plan interventions on cases identified with nutritional risk must be performed in 24-48 hours after being determined that are at nutritional risk and/or admitted to the facility. 1. The following was identified while appropriateness of patient assessment of cases identified with nutritional risk or in potential of develop nutritional problems with the clinical dietitian (employee #13) was performed on 08/28/24 from 1:30 PM till at 2:55 PM: a. RR#16 is an 86-year-old female patient admitted on 08/17/24 with a diagnosis of Pneumonia. On the admission orders instead of ordering a diet the physician wrote: diet evaluation. This case was admitted and sent to the ward from the emergency room on 08/17/24 (Saturday) at 3:45 PM. While reviewing and discussing the case with the clinical dietitian (employee #13) on 08/28/24 at 1:50 PM it was informed that on Saturday facility had available the services of a clinical dietitian to evaluate cases consulted by physician, referred by nursing personnel or identified as in nutritional risk. She explains that this case was not consulted by physician or referred by nursing personnel to be evaluated by clinical dietitian after the admission. She stated that clinical dietitian was at the hospital evaluating patients on 08/17/24 until 4:00 PM. The patient remained Nothing by mouth (NPO) until 08/19/24 at 12:15 PM when was evaluated, because on Sunday there is no clinical dietitian assigned to be available, to evaluate patients. Clinical dietitian (employee #13) stated on interview on 08/28/24 at 2:20 PM, that no matter what there is no clinical dietitian assigned to be available outside working hours or on Sundays, the case could have been consulted or referred by phone. Dietitians stated that if the clinical dietitian understand that the case require face to face evaluation facility authorize these personnel to come to the hospital outside working hours or on Sunday. b. RR#14 is a 77-year-old male patient admitted on 08/07/24 at 6:15 PM with a diagnosis of Clinical Sepsis as Dysphasia. This patient was admitted with an order of Nothing by mouth (NPO). This case was not consulted by physician or referred by nursing personnel, until 08/09/24 at 8:50 PM when was consulted by a physician to be evaluated by a clinical dietitian. The case was evaluated by a clinical dietitian on 08/10/24. Clinical dietitian (employee #13) stated on interview on 08/28/24 at 2:30 PM, that this case must be evaluated in a period of 24-48 hours after admission, because had nutritional risk due to his diagnosis. Facility failed to have a mechanism in place to ensure that patients identified at nutritional risk receive dietitian evaluations as early as possible so interventions can be initiated to prevent complications and adverse outcomes.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47384 Based on tests to equipment, interviews and observations made during the survey for Life Safety from fire with the Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101. Findings include: The Life Safety from Fire survey was performed from 08/27/2024 through 08/29/2024 from 8:00 AM till 4:00 PM with the facility Compliance Officer (Employee #27) ,for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS2567 form (K223, K291, K293, K323, K325, K343, K345, K355, K372, K751, K753, K781, K902, K911, K920, K923)”

“FACILITIES CFR(s): 482.41(c) (d) Standard: Facilities. The hospital must maintain adequate facilities for its services. This Standard is not met as evidenced by: 15884 Based on observations performed during observational tour at the emergency room, radiology department, nuclear medicine department and sleep laboratory room, it was determined that the facility failed to maintain adequate facilities for its services. Findings include: 1. During the initial observational tour at the emergency room department, with the Director of nursing (employee #1) and Nursing supervisor of the emergency room (employee #7) the following was observed on the area on 08/27/24 at from 10:35 AM through 11:50 AM: a. In the women’s bathroom facilities located on the waiting area, nurse call system does not have the call cord to activate the system. b. The women’s bathroom facilities located on the waiting area, had two cubicles, one of them is permanently closed. Accordingly with information provided by the nursing supervisor of the emergency room (employee #7) on 08/27/24 at 10:40 AM this toilet facility is damaged since several days ago and its pending to be fixed. c. The women’s bathroom facilities located on the waiting area, had two handwashing sinks, one of the sinks did not have soap dispenser. d. The women’s bathroom facilities located on the waiting area, had one wall mounted toilet paper dispenser, this dispenser is observed without the hinged cover. This does not permit better hygiene. e. At the ceiling area located above the entrance door of the Women’s bathroom facilities located at the waiting area it was observed missing tiles. e. In the men’s bathroom facilities located on the waiting area, the nurse call system had the call cord to activate the system too short (about 2 inches long). In the event that a patient had an emergency and fall to the floor he/she cannot activate the system. f. Men’s bathroom facilities located on waiting area had broken tiles on the floor, on the walls and it was observed in need of cleaning and maintenance. g. At the pediatric area in the crash cart it was observed metal rack were personnel put the defibrillator. This metal rack is observed corroded with rust. h. The pediatric area had 4 cubicles, three to locate stretchers and one to locate a crib. The gypsum board wall located behind the stretchers and crib is observed broken with peeled paint. i. At the gynecology cubicle it was observed a three-legged stool with wheels with rust on the metal components. j. At the housekeeping room it was observed a missing tile on the ceiling area, this promote that equipment and supplies storage at this area are exposed to the environment located over the ceiling and electric cables and telecommunication devices. Two stained tiles were observed at this room ceiling. k. A multigender bathroom located inside emergency room was observed the call system had the call cord to activate the system too short (about 2 inches long). 2. During the observational tour at the radiology department, with the supervisor of the area (employee #14) the following was observed on the area on 08/29/24 at from 9:15 AM through 10:10 AM: a. At the room located near the fluoroscopy room it was observed two ceiling tiles with brown stains. b. At the Computerized tomography room #2 it was observed a table used by a nurse who perform venous cannulation to patients before procedures. This table had broken Formica. c. At the radiology material storage area, it was observed two ceiling tiles with brown stains. d. At the Computerized tomography room #1 it was observed a built -in handwashing sink in a wooden cabinet. The sink and the wooden of the cabinet were observed with damage due to water hardness. 3. During the observational tour at the nuclear medicine department, with the supervisor of the area (employee #15) the following was observed on the area on 08/29/24 at from 10:50 AM through 11:45 AM: a. The area for storage and preparation of radiopharmaceuticals for use in imaging procedures was observed with ceiling tiles in bad condition, deteriorated, with black stains. b. The area where radioactive medicines are prepared had an extraction system located on the ceiling. Area where components of the system are located on the ceiling is observed with ceiling tiles in bad condition, deteriorated, with black stains. 4. During the observational tour at the sleep laboratory room, with the supervisor of the area (employee #16) the following was observed on the area on 08/29/24 at from 1:00 PM through 1:45 PM: a. The room used to diagnose sleep disorders, located on the third floor does not have a cozy and home like environment. b. Bed and night table located at this room is observed with broken pieces on their wooden components. c. Room windows curtains does not have full coverage in order to promote good block light illumination. d. The floor on the room had an area where there is located a metal division that makes the floor uneven. This causes an abrupt change in vertical elevation or horizontal separation of this walking surface. This metal device on the room floor could be a tripping hazard for the person who stays at night at the room.”

“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: 47632 Based on the observational tour made during the physical environment survey, it was determined that the structure of this facility was not maintained to protect and safeguard supplies and equipment to ensure safety and quality. Findings include: 1. During the tour made in the holding area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 9:24 AM, the ceiling lights were observed not working. b. At 9:24 AM, the stained acoustics were observed. c. At 9:25 AM, Observed peeling tiles and peeling paint in first bathroom. d. At 9:29 AM, the acrylic cover of the light fixture in the first bathroom was observed broken. e. At 9: 30 AM, a cement frame between cubicle 6 and cubicle 7 was observed cracked and missing paint. f. At 9:33 AM, lack of cleanliness was observed in the area. g. At 9:35 AM, Observed chipped sink in second bathroom. h. At 9:41 AM, in the last cubicle, a mattress with plastic placed on the floor was observed. i. At 9:49 AM, clean sheets were observed placed on the bariatric chair in the last cubicle. An operating room supervisor (employee #17) was interviewed and stated that there is a room to put clean sheets that an employee placed incorrectly. j. At 10:00 AM, it was observed on 08/04/2024 that shift 3-11 did not perform the defibrillator check according to policy. k. At 10:05 AM, in the storage area, two boxes of stretcher paper were observed placed on the floor. l. At 10:07 AM, acoustic stains were observed in the storage area. m. At 10:10 AM, observed in storage area with light receptacle cover removed. n. At 10:17 AM, a broom and dustpan were observed in the storage area. 2. During the tour made in hallway area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 10:33 AM, a box of 100ml 9% Nss sodium chloride, 12 packages, was observed placed on the floor. b. At 10:38 AM, stained acoustics were observed. c. At 10:42 AM, it was observed that the ceiling light bulbs were not working. 3. During the tour made use room area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 10:54 AM, observed at the entrance to the broken utility room. b. At 10:59 AM, it was observed that autoclave II was not working. c. At 11:00 AM, stained acoustics were observed. d. At 11:03 AM, ceiling lights observed not working. e. At 11:05 AM, observed peeling paint in the warehouse. 4. During the tour made instrument washing area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 11:11 AM, dark spots were observed on the plastic of the ceiling light. b. At 11:13 AM, observed peeling paint and moisture in laundry area. c. At 11:16 AM, it was noted in the second wash next to X Ray that the Avagard foot pump was not found. 5. During the tour made X Ray area on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 11:20 AM, two laryngoscopes (MAC #3 and MAC #4) were observed open. b. At 11:28 AM, a machine panel was observed lying on the ground. c. At 11:30 AM, intravenous support was observed with dark spots and lack of paint. 6. During the tour made anesthesia warehouse area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 11:33 AM, it is observed on the ceiling where the exit is located in front of the anesthesia warehouse, a crack and peeling paint were found. 7. During the tour made surgical material warehouse area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 11:35 AM, it was observed that the nurse anesthetist’s (employee #20) briefcase was not locked. The following medications were found: i. Three vials of Amiodarone Hydrochloride 150 mg/3 ml expired on 4/2024. ii. One vial of spinal Bupivacaine 15 mg/2 ml expired on 4/2024. iii. A vial of Rocuronium 5 mg/5 ml with an opening sheet when the vial was closed. iv. One vial of Diphenhydramine Hydrochloride 50mg/ml expired on 6/2024. v. One vial of Phenylephrine HCL 10mg/ml expired on 4/2024. vi. One vial of Flunazenil 0.5mg/5ml expired on 03/2024. vii. One Lidocaine HCL 1% 200mg/20ml expired on 08/01/2024. viii. A vial of Atracurium 50mg/5ml with an opening sheet when the vial was closed. ix. Inside the briefcase, a broken vial of neostigmine methyl sulfate 5 mg/10 ml was observed. 8. During the tour made sterile material warehouse area on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 11:55 AM, stained acoustics were observed. 9. During the tour made difficult and pediatric airway cart area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 11:57 AM, two 4.5 mm endotracheal tubes were noted to expire on 06/17/2024. b. At 11:59 AM, a 4.0 mm endotracheal tube were noted to expired on 08/13/2024. c. At 12:02PM, a 5.0 mm endotracheal tube were noted to expired on 05/08/2023. d. At 12:08 PM, a 5.5 mm endotracheal tube were noted to expired on 06/19/2023. e. At 12:13 PM, a Suction catheter #10 was observed open. 10. During the tour made nursing counter area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 1:41 PM, broken Formica on the nursing desk was observed. 11. During the tour made at the operating room area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 1:45 PM, all unidentified rooms (without numbers) were observed. b. At 1:48 PM, in room #1, receptacles with dark spots were observed. c. At 1:57 PM, room #1, stained door hinges were observed. d. At 2:00 PM, room #1, an expired Angio #22 was observed in the anesthesia surgical material cart on 07/31/2024. e. At 2:05 PM, room #1, an open 6.0 mm endotracheal tube was observed in the anesthesia surgical material cart. f. At 2:08 PM, room #1, open 6.5 mm endotracheal tube was observed in the anesthesia surgical material cart. g. At 2:12 PM, room #1, an open 8.0 mm endotracheal tube was observed on the anesthesia surgical material cart that expired on 08/13/2024. h. At 2:18 PM, in room #1, a YanKaver connection was observed and the suction tube of the anesthesia surgical material cart expired on 01/2024. i. At 2:22 PM, in room #1 Seroflurance, UPS 250 ml was found in the accessible anesthesia cart. The inhalation anesthetic was not blocked. j. At 2:25 PM, room #2, three intravenous supports with dark spots were observed. k. At 2:28 PM, in room #2, the ceiling was observed to have peeling paint. l. At 2:32 PM, room #2 peeling door frame. m. At 2:35 PM, observed in room #2 in open MAC Surgical Supply Cart #4. n. At 3:00 PM, the temperature and relative humidity recording was observed altered in orthopedic room, holding area, recovery, quarter tray, sterile material room, autoclave, packing room, tray preparation room, room #216, room #217, room #1, room #2, room #3, room #4, room #5, room #6, room #7, and room #8 from January to July 2024 according to the policy. 12. During the tour made Ambulatory Surgery area with Compliance Officer (employee #33), and Ambulatory surgery supervisor (employee #35) on 08/28/2024 at 1:30 PM through 4:00 PM, the following was found: a. At 2:56 PM, the negatoscope with dark spots was observed in room #4. b. At 3:10 PM, in room #4, the unlocked anesthesia cart was found placed with 8 ml of propofol in a 20 ml syringe without identification of the patient in charge of the nurse anesthetist (employee #21). c. At 3:11 PM, in room #4, the unlocked anesthesia cart was found placed with 1 ml of propofol in a 3 ml syringe without identification of the patient in charge of the nurse anesthetist (employee #21). d. At 3:15 PM, observed in room #3 a 100 ml of sodium chloride 9% Nss that expired on 6/2024. e. At 3:20 PM, an open 6.5 mm endotracheal tube was observed. f. At 3:27 PM, the surgical sink between room #3 and room #4 was observed and the doors were broken. g. At 3:38 PM, cracks and peeling paint were observed in the biohazard trash room. 13. During the tour made Endoscopy Center area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/28/2024 at 10:00 AM through 4:00 PM, the following was found: a. At 11:32 AM, 4.0 mm endotracheal tube expired 08/13/2024 was found in the chart cart. b. At 11:40 AM, the temperature and relative humidity recording was observed altered in room #1, room #2, preparation area, surgical material room and supply room from January to July 2024 according to the policy. 14. During the tour made Rehabilitation area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/29/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 10:00AM, spots were observed in the acoustic system of the speech pathology clinic. b. At 10:17 AM, N-K table was observed with dark stains and lack of paint. c. At 10:22 AM, intravenous support was observed with dark spots. d. At 10:39 AM, observed arm pulleys with dark stains and missing paint.”

“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 the observational tour in the surgery ward, ambulatory ward, endoscopy ward, physical medicine and rehabilitation with the operating room supervisor (employee #17), and compliance officer (employee # 33), it was determined that the facility failed to provide standards for infection control related to preventing and controlling the transmission of infectious within the hospital. Findings include: 1. During the tour made in the holding area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 9:25 AM, dusty air ducts were observed. b. At 9:27 AM, in the first bathroom, a man’s urinal was observed on the floor. c. At 9:55 AM, in the last cubicle, a mattress covered with plastic was observed placed on the floor. 2. During the tour made in the operating room area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 through 08/29/2024 at 9:20 AM through 4:00 PM, the following was found: a. On 08/27/2024 at 11:35 AM, in the surgical material storage area, it was observed that the nurse anesthetist’s (employee #20) briefcase was not locked. The following medications were found: i. Three vials of Amiodarone Hydrochloride 150 mg/3 ml expired on 4/2024. ii. One vial of spinal Bupivacaine 15 mg/2 ml expired on 4/2024. iii. A vial of Rocuronium 5 mg/5 ml with an opening sheet when the vial was closed. iv. One vial of Diphenhydramine Hydrochloride 50mg/ml expired on 6/2024. v. One vial of Phenylephrine HCL 10mg/ml expired on 4/2024. vi. One vial of Flunazenil 0.5mg/5ml expired on 03/2024. vii. One Lidocaine HCL 1% 200mg/20ml expired on 08/01/2024. viii. A vial of Atracurium 50mg/5ml with an opening sheet when the vial was closed. ix. Inside the briefcase, a broken vial of neostigmine methyl sulfate 5 mg/10 ml was observed. b. On 08/27/2024 at 1:48 PM, the head nurse anesthetist (employee #18) and nurse anesthetist (employee #21) were observed with gel nails according to administrative order #284. c. On 08/27/2024 at 2:00 PM, in room #1, the anesthesia surgical material cart was observed, open packaged endotracheal tubes of 6.0 mm and 6.5 mm. d. On 08/27/2024 at 2:10 PM, in room #2, dusty air ducts and poorly cleaned monitor cables were observed. e. On 08/29/2024 at 10:03 AM, during the inguinal hernia procedure, it was observed that the nurse anesthetist (employee #24) put on gloves on 6 occasions without washing her hands with soap and water or hand sanitizer. f. On 08/29/2024 at 10:10 AM, during the inguinal hernia procedure, it was observed that the circulating nurse (employee #25) put on gloves on 2 occasions without washing her hands with soap and water or hand sanitizer. g. 08/29/2024 at 10:13 AM, during the inguinal hernia procedure, the anesthesiologist (employee #26) was observed entering room #5 without shoe covers and without washing his hands before putting on sterile gloves before administering spinal anesthesia. 3. During the tour made in the endoscopy center area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/28/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 11:32 AM, a registered nurse (employee #22) was observed changing gloves on two occasions without washing her hands with soap and water or hand sanitizer. 4. During the tour made in the Ambulatory surgery area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/28/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 3:30 PM, a 6.5 mm endotracheal tube with open packaging was observed.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 47632 Based on the observational tour at surgery ward, ambulatory ward, endoscopy ward, physical medicine and rehabilitation, it was determined that the facility failed to include method for preventing and infection control, including maintaining a clean and sanitary environment within the hospital. Findings include: 1. During the tour made in the holding area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 9:24 AM, dusty air ducts were observed. b. At 9:30 AM, unlabeled primary and secondary lines were observed in cubicles 1 and 3. c. At 9:33 AM, it was observed that the holding area lacked cleanliness. d. At 10:05 AM, two boxes of stretcher paper were observed placed directly on the floor of the warehouse area. e. At 10:17 AM, it was found in a surgical supply store with a broom and dustpan. 2. During the tour made in the X ray area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 11:28 AM, a machine panel was observed placed directly on the floor and an intravenous support with stains and lack of paint. 3. During the tour made in the operating room area with Compliance Officer (employee #33), and Operating Room Supervisor (employee #17) on 08/27/2024 at 9:20 AM through 4:00 PM, the following was found: a. At 1:48 PM, in room #1, plugs with dark stains were observed. b. At 2:25 PM, room #2, three intravenous supports with dark spots were observed. 4. During the tour made Ambulatory Surgery area with Compliance Officer (employee #33), and Ambulatory surgery supervisor (employee #35) on 08/28/2024 at 1:30 PM through 4:00 PM, the following was found: a. At 2:56 PM, the negatoscope with dark spots was observed in room #4. 20423 During the tour performed in the Hemodialysis Area, nine floor, seven floor, six floor, and five floor with Epidemiologist Nurse employee #38, 08/27/2024 through 08/28/2024 from 9:00AM till 4:00 PM, the following was found: 1. On the first floor the Hemodialysis Area was observed: a. A metal shelf was observed with pilling paint and rust in the entrances of the area. b. The wall was observed with pilling paint c. In the back of station #3 was observed tape in the water tube. d. In the Reverse Osmosis area was observed in the floor water with 6 blue pad places to absorb. e. The weight scales was observed with rust. and the rubber floor was broken. 2. In the Nine floor was observed: a. The clean sheets cart was observed with evidence of tape glue. b. Resident foley catheter was observed unlabeled, room 909 A. c. Bed Rails with peeling paint room 909A. d. Basin was observed directed in the floor room 909, 910. e. The oxygen cannulas was observed unlabeled room 910A. f. The canulization and blood sample cart was observed with residual of tape glue. g. The Regular trash room and the Biohazard trash room was observed opened with tape place in the lock space that no permit to close and lock the door. 3. In the seven floor was observed: a. The door to entrance to patient room was observed with pilling paint and broken Formicas room 704. b. The Regular trash room was observed opened with paper place in the lock space that no permit to close and lock the door. 4. In the six floor was observed: a. Bed Pan was observed direct in the floor room 604A. b. The bathroom door was observed with broken Formicas and not fits room 606, 607. c. Then dirty clothes room was observed opened. d. The Biohazard trash room was observed opened with the key place in the knob. 5. In the five floor was observed: a. The wall was observed with pilling paint room 502. b. Basin was observed directed in the floor room 504.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 15884 Based on review of 12 clinical records, policies/procedures and interview with the Social Worker (employee #2), it was determined that the facility failed to establish timeframe and perform the initial evaluation at an early stage of hospitalization of patients who are likely to suffer adverse health consequences upon discharge in absence of discharge planning, as well as for other patients upon the request of the patient representatives. This deficient was identified in 5 out of 12 patients evaluated for discharge planning (RR#8, RR#11,RR#12,RR#13 and RR#16). Findings include: Upon review of the facility’s policy for discharge planning last update on August 2024, Policy stated on the procedures that is going to be the responsibility of the medical staff during admission and before the discharge from facility; to identify patient’s needs for continuity of care and discharge planning process. Policy also stated that nursing personnel must assess patient’s needs for the continuity of care and discharge planning process and if determine that need discharge planning for the continuity of care when discharge from facility must refer the case to the discharge planning process. It was identified that this facility’s policy did not have establish a time frame to perform the initial assessment of patients who consulted by a physician after being determine that are likely to suffer adverse health consequences upon discharge in absence of discharge planning as well as for other patients referred by the nursing personnel. 1. The surveyor asked the of Social Worker (employee #2), on 08/28/24 at 10:15 AM if facility had established a time frame to perform the initial assessment for the discharge planning evaluation and she stated that for cases who are received by a consult of a physician they establish a 24 hours after admission as the time frame to evaluate the case and begin the discharge planning process. She stated that other cases referred by a member of health care personnel or patient’s representatives are evaluated, but facility had not established a time frame or criteria for establish priorities on those cases. She stated during interview that discharge planning department evaluate all Medicare and Medicare advantage cases and screen other cases based on the diagnosis, they know that must need discharge planning process but that for those cases they had not establish the time frame in their policies and procedures for the initial assessment. She explains that facility promote that patients who are likely to suffer adverse health consequences upon discharge in absence of discharge planning as well as for other patients upon the request of the patient representative’s they tried to evaluate them in 24 hours after admission. 2. The following was identified during the review of cases for discharge planning with the clinical dietitian (employee #2) on 08/28/24 from 9:30 AM till 11:55 AM: a. RR#8 is a 91-year-old male patient admitted on 08/23/24 with a diagnosis of Urinary Tract Infection. This is a Medicare Advantage case. While being evaluated with the Social Worker (employee #2) of the hospital on 08/28/2024 from 10:25 AM it was informed that this case was evaluated by discharge planning program on 08/26/24 in 72 hours after being admitted to receive services at the facility. b. RR#11 is a 63-year-old male patient admitted on 08/08/24 with a diagnosis of Cellulitis of Lower Limb. This is a Medicare Advantage case. This case is not evaluated by the discharge planning program since admission. While reviewing the case with the Social Worker (employee #2) of the hospital on 08/28/2024 from 11:50 AM it was identified that there is a possibility that this case was discharge home with intravenous antibiotics. No initial evaluation by discharge planning was performed not even by being consulted by a physician, referred by nursing personnel or screen due to being a case of Medicare advantage or considering his admission diagnosis; until 08/28/24 twenty days after being admitted to the hospital to receive treatment. c. RR#12 is a 77-year-old female patient admitted on 08/23/24 with a diagnosis of Cellulitis on Left Leg. This is a Medicare Advantage case. While being evaluated with the Social Worker (employee #2) of the hospital on 08/28/2024 from 10:35 AM it was informed that this case was evaluated by discharge planning program on 08/26/24 but the documentation was not performed. No information was provided in relation with discharge planning assessment of needs for continuity of care of this case. d. RR#13 is a 63-year-old male patient admitted on 08/20/24 with a diagnosis of Cellulitis on the Abdominal Wall. This is a Medicare Advantage case. While being evaluated with the Social Worker (employee #2) of the hospital on 08/28/2024 from 10:55 AM it was informed that this case was evaluated by discharge planning program on 08/26/24 but the documentation was not performed. No information was provided in relation with discharge planning assessment of needs for continuity of care of this case. e. RR#16 is an 86-year-old female patient admitted on 08/17/24 with a diagnosis of Pneumonia. This is a Medicare Advantage case. While being evaluated with the Social Worker (employee #2) of the hospital on 08/28/2024 from 11:10 AM it was informed that this case was evaluated by discharge planning program on 08/19/24. This patient is dependent of Oxygen and is receiving enteral nutrition. Discharge planning program evaluate this case 48 hours after admission instead in 24 hours as informed by the Social Worker (employee #2) of the hospital on 08/28/24 at 10:15 AM as referred what should be. d. RR#10 is a 72-year-old male patient admitted on 08/17/24 with a diagnosis of Respiratory Failure and Hypoxia. This is a Medicare Advantage case. Initial assessment for discharge planning was performed on 08/27/24 after being consulted by a physician to the discharge planning service. While being evaluated with the Social Worker (employee #2) of the hospital on 08/27/2024 at 11:40 AM it was identified that the patient was discharged on 08/27/24. For the continuity of care of this patient Home Care, ambulance, wheelchair and other medical equipment was ordered and is being coordinated the same day the patient was discharged.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 15884 Based on review of twelve clinical records, policies/procedures and interview with the Social Worker (employee #2), it was found that the facility failed to establish timeframe and perform the initial evaluation at an early stage of hospitalization of patients who are likely to suffer adverse health consequences upon discharge in absence of discharge planning as well as for other patients upon the request of the patient representatives. This deficient was identified in 1 out of 12 patients evaluated to determine evaluate if facility for discharge planning (RR#16). Findings include: Upon review of the facility’s policy for discharge planning last update on August 2024, Policy stated on the procedures that is going to be the responsibility of the medical staff during admission and before the discharge from facility; to identify patient’s needs for continuity of care and discharge planning process. Policy also stated that nursing personnel must assess patient’s needs for the continuity of care and discharge planning process. It was identified that this facility’s policy did not had establish a time frame to perform the initial assessment of patients who consulted by a physician after being determine that are likely to suffer adverse health consequences upon discharge in absence of discharge planning as well as for other patients referred by the nursing personnel. 1. The surveyor asked to the of Social Worker (employee #2), on 08/28/24 at 10:15 AM if facility had established a time frame to perform the initial assessment for the discharge planning evaluation and she stated that for cases who are received by a consult of a physician they establish a 24 hours after admission as the time frame to evaluate the case and begin the discharge planning process. She stated that other cases referred by member of health care personnel or patient’s representatives are evaluated but facility had not established a time frame or criteria for establish priorities on those cases. She stated during interview that discharge planning department evaluate all Medicare and Medicare advantage cases and screen other cases that based on the diagnosis, they know that must need discharge planning process but that for those cases they had not establish the time frame in their policies and procedures for the initial assessment. She explains that facility promote that patients who are likely to suffer adverse health consequences upon discharge in absence of discharge planning as well as for other patients upon the request of the patient representative’s they tried to evaluate them in 24 hours after admission. 2. The following was identified during the review of cases for discharge planning with the clinical dietitian (employee #2) on 08/28/24 from 9:30 AM till 11:55 AM: a. RR#10 is a 72-year-old male patient admitted on 08/17/24 with a diagnosis of Respiratory Failure and Hypoxia. This is a Medicare Advantage case. Initial assessment for discharge planning was performed on 08/27/24 after being consulted by a physician to the discharge planning service. While being evaluated with the Social Worker (employee #2) of the hospital on 08/27/2024 at 11:40 AM it was identified that the patient was discharged on 08/27/24. For the continuity of care of this patient Home Care, ambulance, wheelchair and other medical equipment was ordered and is being coordinated the same day the patient was discharge. Facility failed to promote that the discharge planning evaluation is performed in a timely basis to ensure the appropriate arrangements for post-hospital care will be made, in order to manage situations that may occur before discharge and avoid unnecessary delays in discharge process.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 15884 Based on review of twelve clinical records, policies/procedures and interview with the Social Worker (employee #2), it was found that the facility failed to maintain documentation of the discharge planning assessment on the clinical record who include all arrangements made. This deficient was identified in 2 out of 12 patients evaluated for discharge planning (RR#12 and RR#13). Findings include: Upon review of the facility’s policy for discharge planning last update on August 2024, Policy stated on the procedures that is going to be the responsibility of the medical staff during admission and before the discharge from facility; to identify patient’s needs for continuity of care and discharge planning process. Policy also stated that nursing personnel must assess patient’s needs for the continuity of care and discharge planning process and if determine that need discharge planning for the continuity of care when discharge from facility must refer the case to the discharge planning process. Policy establishes that the discharge planning assessment and re-assent must be documented on the clinical record and that this documentation must include all arrangements made. 1. The following was identified during the review of cases for discharge planning with the clinical dietitian (employee #2) on 08/28/24 from 9:30 AM till 11:55 AM: a. RR#12 is a 77-year-old female patient admitted on 08/23/24 with a diagnosis of Cellulitis on Left Leg. This is a Medicare Advantage case. While being evaluated with the Social Worker (employee #2) of the hospital on 08/28/2024 from 10:35 AM it was informed that this case was evaluated by discharge planning program on 08/26/24 but the documentation was not performed. No information was provided in relation with discharge planning assessment of needs for continuity of care of this case. b. RR#13 is a 63-year-old male patient admitted on 08/20/24 with a diagnosis of Cellulitis on the Abdominal Wall. This is a Medicare Advantage case. While being evaluated with the Social Worker (employee #2) of the hospital on 08/28/2024 from 10:55 AM it was informed that this case was evaluated by discharge planning program on 08/26/24 but the documentation was not performed. No information was provided in relation with discharge planning assessment of needs for continuity of care of this case.”

“POST-ANESTHESIA EVALUATION CFR(s): 482.52(b)(3) [The policies must ensure that the following are provided for each patient:] A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures, which have been approved by the medical staff and which reflect current standards of anesthesia care. This Standard is not met as evidenced by: 47632 Based on the review of eighteen records reviewed (R.R) interview with the Operating Room Supervisor (employee #29) and Ambulatory Surgery Supervisor (employee #35), it was determined that the facility failed to ensure that outpatients are evaluated and called after 24 hours after the surgery was performed to ensure acceptable standards of practice for 9 out of 18 records reviewed (R.R #16, #17, #18, #19, #21, #23, #26, #27, #28). Findings include: 1. During the review of record (R.R #16, #17, #18, #19, #21, #23, #26, #27, #28) on 08/27/2024 through 08/29/2024 at 9:20 AM through 4:00 PM, it was evident that no calls were made more than 24 to 48 hours after the surgeries. 2. The facility did not ensure that nursing staff made follow-up calls to outpatients within 24 to 48 hours.”

“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: 47632 Based on the observational tour with the Physical Therapy supervisor (employee #30), It was determined that the facility failed and did not ensure that the standards and procedures manual for the services offered and the creation of the policy and procedure for temperature monitoring of the cold pack units was updated. Findings include: 1. During the interview with the Physical Therapy supervisor on 08/29/2024 at 1:45 PM, the following was found: a .Reviewing the rules and procedures manual, it was found that it had not been updated since 03/12/2014. The Physical therapy supervisor (employee #30) was interviewed and stated that she was in the process of updating. b. Reviewing the policies and procedures, the ColPaCs care policy was not found. The Physical Therapy supervisor (employee #30) only provided the manufacturer’s instructions.”

“ORDERS FOR RESPIRATORY SERVICES CFR(s): 482.57(b)(3) Services must only be provided under the orders of a qualified and licensed practitioner who is responsible for the care of the patient, acting within his or her scope of practice under State law, and who is authorized by the hospital’s medical staff to order the services in accordance with hospital policies and procedures and State laws. This Standard is not met as evidenced by: 20423 Based on the review of five medical records, policies/procedures, it was determined that the facility failed to ensure that services are provided in accordance with the physician’s orders related to how many hours was given, assessment and re-assessment post therapy, physician’s lack of written respiratory therapy reorder in accordance to standards of practice, medical orders not according of policies and procedures for 2 out of 5 clinical records reviewed (RR #5 and #46). Findings include: Five medical records were reviewed on 08/28/2024 from 2:00 till 4:00 PM of patients who received respiratory therapy with the respiratory therapy coordinator employee #37, provided evidence of the following: 1. R.R #5 is a 61-year-old male who was admitted on 08/22/2024 with a diagnosis of Hypoxia and Anemia. During the record review performed on 08/28/2024 at 2:39 PM with Respiratory Therapist coordinator employee #37, provide evidence that the physician ordered on 08/22/2024 at 6:00 AM Atrovent 2.5% by power nebulizer (PN) every 4 hour and a Ventury (VM) at 35%, however on 08/24/2024 at 8:00 AM and at 12:00 PM no evidence was found in the medication Kardex that the respiratory therapist administered the therapy. On 08/24/2024 at 8:25 PM the respiratory therapist documented in their note that patient have a VM at 40%, however no evidence was found that the physician increases the VM. and at 11:30 PM no evidence was found the treatment documentation. On 08/27/2024 at 12:25 AM the respiratory therapist documented that patient has a nasal canula at 3 litter per minute, no evidence was found that the physician ordered the change from VM to canula. On 08/26/2024 at 9:00 PM the physician order place the VM 35% with Humidifier, however the respiratory therapist did not document the use of humidifier on 08/27/2024 at 3:50 PM, and on 08/28/2024 at 12:10 AM. 2. R.R #46 is a 73-year-old female who was admitted on 08/16/2024 with a diagnosis of Sepsis. During the record review performed on 08/28/2024 at 3:13 PM with Respiratory Therapist coordinator employee #37, provide evidence that the physician ordered on 08/16/2024 at 3:20 PM a Non Reabreating mask, on 08/20/2024 at 11:10 AM VM at 55% and on 08/25/2024 at 6:30 PM VM %0% humidifier. No evidence was found that on 08/16/2024 at 6:00 PM the respiratory therapist performed the initial evaluation to the patient. No evidence was found on 08/24/2024 the respiratory therapist documented. No evidence was found on 08/25/2024 at 6:30 PM, on 08/26/2024 at 3:10 PM, on 08/27/2024 at 8:40 AM and 08/28/2024 at 8:43 AM the respiratory therapist documented that the VM was place with humidifier.”

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/29/2024 at 1:00 PM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials’ effort to maintain an integrated response during s disaster or emergency situation. Findings include: During the review of the facilities Emergency Preparedness Program with the Compliance Official (employee #27) on 08/29/2024 at 1:00 PM through 4:00 PM it was noted that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials as required under §482.15(a)(4) of the Emergency Preparedness.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/29/2024 at 1:00 PM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures to track the location of on-duty staff and sheltered patients in the hospitals facility’s care during an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the Compliance Official (employee #27) on 08/29/2024 at 1:00 PM through 4:00 PM it was noted that the EP failed to have written procedures to document the specific name and location of the receiving facility or other location.”

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/29/2024 at 1:00 PM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide means to shelter in place for patients, staff and volunteers who remain in the facility. Findings include: During the review of the facilities Emergency Preparedness Program with the Compliance Official (employee #27) on 08/29/2024 at 1:00 PM through 4:00 PM it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the Hospital during and after an emergency.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/29/2024 at 1:00 PM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to stablish the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act. Findings include: During the review of the facilities Emergency Preparedness Program with the Compliance Official (employee #27) on 08/29/2024 at 1:00 PM through 4:00 PM it was noted that the EP failed to include policies and procedures which outline the facility’s role in the provision of care and treatment under section 1135 waivers during a declared public health emergency in alternate care sites as required under §482.15(b)(8).”

“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 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to observe that hazardous area enclosure are self-closing and kept in the closed position as required in 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8. Findings include: 1. On 08/27/2024 approximately at 9:35 AM the Patholgy Room door located on the Surgery Department was found unlocked in the open position. 2. On 08/27/2024 approximately at 9:35 AM the Mantainance Equipment Room Door on the Surgery Department did not have self closing mechanism and was found unlocked. 3. On 08/28/2024 approximately at 9:45 AM the Mantainance Equipment Room Door on the Diet Department did not have self closing mechanism and was found unlocked. 4. On 08/28/2024 approximately at 1:45 PM Bio Hazard Room on ninth floor did not have self closing mechanism and was found unlocked. 5. On 08/28/2024 approximately at 2:15 PM Bio Hazard Room on seventh floor did not have self closing mechanism and was found unlocked.”

“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 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to provide emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9.. Findings include: During made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM the following was observed: 1. No emergency light on exit of Sugicenter. 2. No emergency light on exit and pathway to the outside of the building from the back emergency exit to parking lot on the Surgicenter. 3. No emergency light on hallways of the second floor from Hospital all the way to the Endoscopy Department. 4. No emergency light on Nuclear Medicine waiting room area and hallway.”

“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 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to have exit and directional signs that are displayed in accordance with 7.10 with continuous illumination as required on 19.2.10.1. Findings include: 1. On ER observation area there is no exit sign stating obvious exit pathway, at least three (3) exit signs are needed to state exit route. 2. Exit sign on Endoscopy Department entrance door was found unoperable. 3. On endoscopy room #1 exit sign was found unoperable. 4. Pharmacy Department: a. No exit sign on main door b. No visible exit sign stating obvious exit pathway from computer desk to outside. 5. Nuclear Medicine: a. No exit sign on main door b. No exit sign on hallway stating obvious exit pathway”

“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 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to identify and ensure free acces to emergengy shutt-off valves for medical gases. Findings include: 1. On 08/27/24 approximately at 1:30 PM it was observed that the four (4) zone valves on the Surgicenter were not identified as emergency shut-off valves. 2. On 08/27/24 approximately at 9:30 AM it was observed that the emergency shut-off valves on Surgery Department were blocked by medical equipmnet. 3. On 08/28/24 approximately at 10:30 AM it was observed that the emergency shut-off valves on Endoscopy Department were blocked by chair and trash can.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the faclity falied to comply with Alcohol Based Hand Rub Dispenser (ABHR)regulations in accordance with 8.7.3.1. Findings include: During visual inspection of the Emergeny Department area it was observed: 1. On 08/28/24 approximately at 10:00 AM a ABHR was observed mounted on top of a receptacle (PANEL Y A CKT 17) on Triage 1 room.”

“Fire Alarm System - Notification CFR(s): NFPA 101 Fire Alarm - Notification 2012 EXISTING Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire. 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the faclity did not provide automatical occupant notification in accordance with 9.6.3 by audible and visual signals. Findings include: 1. On 08/28/2024 approximately at 2:15 PM a manual activation devise (Pull Station) was activated, audible notification was heard throughout facility but no visible notification was observed on the devises.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 47384 Based on observation and interview, the facility did not provide and maintain complete and accurate documentation, testing of the fire alarm system by qualified individuals in accordance with the requirements of NFPA 72, 2012 Edition, Section 10.4.3, 10.4.3.1, 10.4.3.2, 14.3.1, 14.4.2.2, 14.4.5 and 23.8.2. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the fire alarm system, proper operation and prompt repair affects all occupants. Findings include: During visual inspection of the alarm panel with facility’s Compliance Officer (Employee #27) on 08/28/2024 proximately at 9:15 AM the following was found: 1. No dated Inspection, Testing and Maintenance (ITM) label on fire alarm panel and fire alarm system batteries.”

“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 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), 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 08/27/2024 approximately at 8:45 AM a fire extinguisher was observed blocked by a printer on Surgery Recovery area. 2. On 08/27/2024 approximately at 10:30 AM two fire extinguishers were observed blocked by wheelchairs and by desk on the Surgicenter area. 3. Fire extinguishers on Surgicenter and on main building were observed exceeding the 5 feet mounting highth”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to comply with smoke barriers integrity on all areas. Findings include: During observations made during the survey for life safety it was identified that material used for fire proofing penetrations do not assure the integrity minimum requirement of 1/2 hour fire resistance for the compartment.”

“Draperies, Curtains, and Loosely Hanging Fabr CFR(s): NFPA 101 Draperies, Curtains, and Loosely Hanging Fabrics Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall. 18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to certify that window curtains and divisional curtains are up to standard with NFPA 701 in accordance with 10.3.1. Findings include: No tag with flame retardant or fire resistant in accordance with standard to NFPA 701 on: 1. Five (5) curtains on Surgery Recovery Area 2. Four (4) curtains on Surgery Recovery Area Fase II 3. Five (5) curtains on Surgicenter 4. Four (4) curtains on Cardiology Department 5. Two (2) curtains on Endoscopy Room 6. Eight (8) curtains on Cathetherism 7. Eight (8) curtains on Cathetherism Holding 8. Four (4) curtains on Nuclear Medicine 9. Ninth floor room dividing curtains 10. Fifth floor window curtains”

“Combustible Decorations CFR(s): NFPA 101 Combustible Decorations Combustible decorations shall be prohibited unless one of the following is met: o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product. o Decorations meet NFPA 701. o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289. o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present. 19.7.5.6 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to prohibit Combustible decorations. 19.7.5.6 Findings include: 1. On 08/28/2024 approximately at 2:35 PM it was observed on the seventh floor nurses pantry cardboard birthday decorations and filled ballons.”

“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 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to prohibit the use of portable heating devices. 18.7.8, 19.7.8 Findings include: On 08/27/24 during observational tour of the facity it was observed: 1. One (1) portable heating device was osberved under desk on the triage of Surgicenter. 2. One (1) portable heating device was osberved under desk on the Doctors office in the ER.”

“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 made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to secure medical gas piping as requiered on Chapter 5 (NFPA 99). Findings include: On 08/28/24 during observational tour of the Emergency Department it was observed: 1. Cublicle #10 and #11 has exposed oxygen piping and un protected gauge that could be affected by stretcher or patient in area.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical 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 6 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to guard electrical live parts as required on Chapter 6 (NFPA 99). Findings include: During observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM the fallowing was found: 1. Unlocked panel found on Ultra Sound Room 2. Unlocked panel found on Orthopedia Warehouse 3. Unlocked panel found on esterilizatiion room on Surgery Unit 4. Unlocked panel found on Opeartion Room #7 5. Unlocked panel found on X Ray Department 6. Unlocked panel found on ninth floor (LP9B)”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to have Hospital grade power cords or multy plugs in hospital areas as required in 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 Findings include: Non Hospital Grade multy-plugs were found in: 1. One (1) on oparation room #7 un the surgery department 2. One (1) on ER waiting area behind vending machines 3. One (1) on X Ray Department 4. One (1) on Nuclear Medicine administrative offices 5. One (1) on Cardiology Department 6. Two (2) on Farmacy”

“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 08/27/2024 through 08/29/2024 from 8:00 AM to 4:00 PM with the facility’s Compliance Officer (Employee #27) and Engineering Director (Employee #4), it was determined that the facility failed to observe precautionary measures to ensure safety on the cylinder storage room as requested on 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) Findings include: On 08/28/24 during observation of the cylinder storage room it was observed: 1. Two (2) NITROUS OXIDE (UN 1070) full tanks were observed un fastened to a cart inside cylinder storage room. 2. One (1) COMPRESSED NITROGEN (UN 1066) empty tank was observed un fastened inside cylinder storage room. 3. One (1) CARBON DIOXIDE (UN 1013) full tank was observed un fastened to a cart in Surgery Department”