Hospital San Carlos Borromeo

“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 fifthteen (15) record reviewed (R.R), it was determined that the facility failed to inform to each Medicare recipients “An Important Message from Medicare” (IM) two days before discharge to execute their rights to appeal facility’s discharge, failed to sign, provide the two forms, or provide the second form and inform patients of the IM requirements for 6 out of 15 close records reviewed (RR) (RR. #25, #27, # 33, # 34, # 40 and # 41). Findings include: Facility policy and procedure related to Policies on notification to the patient or legal representative about patient rights to appeal discharge were reviewed on 08/14/2025 at 9:57 am. 1. R.R. #25 is a 64-year-old male who was admitted on 11/16/2024 with a diagnostic of Acute Kidney Injury, Hypercalcemia, Diabetes Mellitus High Blood Pressure. The record was reviewed on 08/14/2025 at 8:48 am. The patient was discharged home on 01/04/2025. The Important Message from Medicare was provided upon admission on 11/16/2024, however the two days prior discharge Important Message from Medicare was not provided. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided with a standardized notice, “An Important Message from Medicare” (IM). The IM is to be given 2 days before patient’s discharge, providing the rights to appeal their discharge. 2. R.R. #27 is a 69-year-old female who was admitted on 12/28/2024 with a diagnostic of Acute Nephritis Syndrome. The record was reviewed on 08/14/2025 at 10:00 am. The patient was discharged home on 01/07/2025. The Important Message from Medicare was provided upon admission on 12/28/2024, however the two days prior discharge Important Message from Medicare was not provided. According to the regulation at 42 CFR 489.27 (b) which cross reference the regulation at 42 CFR 405.1205, each Medicare beneficiary who is an inpatient must be provided with a standardized notice, “An Important Message from Medicare” (IM). The IM is to be given 2 days before patient’s discharge, providing the rights to appeal their discharge. 51629 Records reviewed with the Discharge Planning coordinator (employee # 20), performed on 08/13/2025 at 1:30 PM: 3. RR # 33 is a 71-year-old male Medicare beneficiary who was admitted on 03/24/2025 with a diagnosis of Heart Failure with reduced Ejection Fraction, Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD). The patient was discharged home on 03/30/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to discharge. 4. RR # 34 is a 79-year-old female Medicare beneficiary who was admitted on 04/10/2025 with a diagnosis of Right Hip Prothesis Dislocation and surgical site infection with Acinetobacter Baumani. The patient was discharged home on 04/25/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to discharge. 5. RR # 40 is a 91-year-old female Medicare beneficiary who was admitted on 08/04/2025 with a diagnosis of Pneumonia, Diabetes Mellitus and Chronic Kidney Disease. The patient was discharged home on 08/08/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to discharge. 6. RR # 41 is a 78-year-old female Medicare beneficiary who was admitted on 07/31/2025 with a diagnosis of Urinary Tract Infection, Dehydration, Acute Kidney Injury and Posterior Reversible Encephalopathy Syndrome. The patient was discharged home on 08/03/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to discharge. The facility failed to inform each patient of their rights at least 2 days prior to discharge.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 51782 Based on 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 lack of physician order and justification for the consent of Do Not Intubate (DNI) and advance directive orientation for 2 out of 2 records reviewed of patient with Do Not Resuscitate DNR and DNI (R.R #6 and #22 ). Findings include: Facility policy provided by Patient Service Officer (employee #16) on 08/14/2025 at 9:34 AM was reviewed. The policy was reviewed on 04/14/2025, “Política De No Resucitar (DNR) y No Intubación (DNI). 1. Policy states in section five that it is the primary care physician’s responsibility to advise the patient and family if they do not wish to receive heroic measures to prolong life. In section seven establishes that the justification for the medical order must be documented in the progress note. In section eight establishes that the medical order must be renewed by the primary care physician every 72 hours and that the reassessment of the patient’s condition must be documented in the progress note if the patient continues to make the same decision. a) R.R #6 is a 77-year-old female who was admitted on Intensive Care Unit (ICU) on 07/17/2025, with a diagnosis of Sepsis, Urinary Tract Infection (UTI), Acute Respiratory Failure. During record review performed on 08/13/2025 with the Supervisor (employee #15), at 10:35 A.M., revealed a consent document to Do Not Intubation (DNI) and Do Not Resuscitate (DNR), signed by a family member on 07/19/2023. The medical order in the system dated 07/23/2025. However, no evidence was found for physician initial and subsequent progress notes for that justify the DNI/DNR and family orientation of the DNI/DNR. No evidence was found that the DNI/DNR order system was renewed every 72 hours. In an interview with the Supervisor (employee #15), of the Intensive Care Unit (ICU) on 08/13/2025 at 11:45 AM, indicates that once the patient has the signed DNR or DNI consent, the record is identified with DNR/DNI status in the treatment Kardex area and that when shift handover is done on each shift patient by patient, visiting all the rooms, they notify which patient has signed consent. When asked by surveyor if they place a colored band or sticker on the patient to identify the patient with DNR/DNI, the supervisor (employee #15) stated that they did not place anything on the patient or the identification band. b) R.R #22 is a 67-year-old female who was admitted on Area C department on 08/08/2025, with a diagnosis of Hypotension, Hematemesis, Upper Gastrointestinal Bleeding (UGIB), History Ca Colon and symptomatic Anemia. During record review performed on 08/12/2025, at 11:31 A.M., revealed a medical order in the system dated 08/08/2025, for consent to Do Not Intubation (DNI) and Do Not Resuscitate (DNR), signed by a family member. However, no evidence was found for physician initial and subsequent progress notes for that justify the DNI/DNR and family orientation of the DNI/DNR. No evidence was found that the DNI/DNR order system was renewed every 72 hours. In an interview with the Head Nurse (employee #13) and Supervisor (employee #14), of the Area C Department on 08/13/2025 at 9:38 AM, both indicates that once the patient has the signed DNR or DNI consent, the record is identified with DNR/DNI status in the treatment Kardex area, a violet stickers put in the identification band is placed on the patient’s arm and that when shift handover is done on each shift patient by patient, visiting all the rooms, they notify which patient has signed consent.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 47632 Based on observations made in the operating room with the supervisor (employee #23) on 08/14/2025, it was determined that the facility failed to ensure the patient’s physical privacy during nursing treatment. Findings include: The Security guard (employee #21) provided the facility policy, last update on April, 2025, “Para la operación del sistema de vigilancia electrónica” on 08/14/2025 at 11:49 AM. The policy states on page 4, Procedure: 11. In the case of devices located inside clinical units, staff must do the following: a. They must draw the curtain immediately after placing the patient on the stretcher and keep it closed while the patient is in the area. b. During transport, they must ensure that the patient is completely covered. 1. On 08/14/2025 at 10:32 AM, during a visit to the holding area located near the operating rooms and endoscopy rooms, observed that there were cameras recording in the direction of the patients. The operating room supervisor (employee #23) was interviewed at 10:40 a.m. and stated that he did not know if they were recording. That the nursing staff then provided treatment to the patient, leaving the curtains open to keep them under observation or in case they needed any assistance. At 10:52 AM, it was observed in the hospital’s security monitoring area that the cameras are located in such a way that patients can be seen when they are receiving treatment. In the holding area, there were no signs indicating that there were cameras and that they were recording at all times. At 11:18 AM, the security guard (employee #21) was interviewed and stated that the security cameras were positioned so that they could see patients and staff entering and exiting. The facility failed to comply with regulations regarding the location of cameras, as this may compromise the privacy of patients while they are receiving treatment.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 51782 Based on review of restraint policy and procedure (P&Ps), interviews with the Head Nurse (employee #13) and Supervisor (employee #14), of the Area C Department, it was determined that facility failed to ensure that patients be free from restraint of any form, and be imposed to ensure the immediate physical safety of the patient, staff member, and be discontinued at the earliest possible, for 1 out of 1 patient in restraint. RR #7. Findings include: Facility policy provided by Supervisor of the Area C Department (employee #14), on 08/13/2025 at 9:35 AM was reviewed. The policy was reviewed on 05/30/2025, “Política Restricción de Pacientes”. Policy states in section one (1) that the doctor will evaluate the patient, to identify risk of harm and observed behavior, need for restriction, the type of restriction and will make a medical order for mechanical restriction. In section eight area d and area e it mentions that the nursing staff will make a nursing evaluation and will document in the electronic clinical record areas to be restricted (maximum three extremities) and types of bands to be used, and in section fourteen it establishes that the medical faculty will evaluate the patient and will renew or revoke the order according to the patient’s need. In a period that does not exceed 24 hours and that every order has a duration of 24 hours so the doctor will renew it daily if necessary. 1. R.R. #7 is an 80-year-old male admitted to the facility on 08/07/2025 with a diagnosis of Dysphagia, Anemia, Pneumonia Aspiration, Acute Kidney Injury (AKI). During the record review performed on 08/13/2025 through 08/14/2025 at 9:30 AM though 10:30 AM it was found that on 08/12/2024 at 12:09 PM the physician ordered restraint due to disruption of therapy. However, the order does not detail the areas to be restricted and what type of restriction should be used. 2. During the record review performed on 08/14/2025 at 10:00 AM with Head Nurse (employee #13) it was observed the registered nurse complete the care assessment document on 08/12/2025 and 08/13/2025 that the patient is restrained, however, no areas where the patient is restrained and what type of restraints are used are noted. It is also observed that on 08/13/2025 the registered nurse for shift 7:00 AM though 3:00 PM did not make a nursing note. 3. The physician ordered the restriction due to disruption of therapy to be renewed on 08/13/2025 at 10:09 PM, 30 hours after the order placed on 08/12/2025. However, the order does not detail the areas to be restricted and what type of restriction should be used.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 20423 Based on four medical records reviewed (R.R.) for restraint, review of restraint policy and procedure (P&Ps), it was determined that the facility failed to ensure that during the use of restraint, Nurses’ continuous assessment and monitoring the patient accordingly with facility policy. This deficient practice was identified in 1 out of 4 records reviewed with restraint. (R.R. 18). Findings include: The Patient Restraint policy and procedure (P&P) was reviewed on 08/12/2025 at 3:10 PM. 1. R.R #18 is a 99-year-old female who was admitted on 08/11/2025 to the emergency room (ER) with a diagnosis of Weakness. During observation rounds in the emergency room on 08/12/2025 at 11:00 am, in cubicle #3, the patient was observed with both arms restrained. A companion was asked how long the restraint had been in place, and he indicated he did not know. During the record review performed on 08/12/2025 at 3:00 PM provide evidence that nurse documented on 8/12/2025 at 6:43 am, patient is combative, attempts to remove nasogastric tube, doctor places restraining orders, patient is restrained per 2. On 08/12/2025 at 6:43 AM the physician places physician order and writes Restraint -initial/ renewable every 24-hour, Behavior requiring restraint/seclusion: violent behavior. On 08/12/2025 at 6:43 AM the nurse documented the Restraint Assessment and documented that patients try to remove the nasogastric tube multiple times, was restraint on left and right upper extremity with soft limb. On 08/12/2025 at 7:21 AM the nurse documented that patients observed restraint in both superior extremities left and right and monitor for change. No evidence was found documented of the nurse assessment every 2 hour accordingly with 482.13(e)(10) and facility P&P. The physician failed to write a complete restraint physician order that included purpose of the restriction, duration the restriction, type of restriction, and parts to be restricted. The physician failed to document in the physician’s progress notes a justification and a face-to-face assessment before restraint.”

“PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT CFR(s): 482.13(g)(1) & (3)(i) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (1) With the exception of deaths described under paragraph (g)(2) of this section, the hospital must report the following information to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint used on the patient during this time.”Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.... (3) The staff must document in the patient’s medical record the date and time the death was: (i) Reported to CMS for deaths described in paragraph (g)(1) of this section; or .... This Standard is not met as evidenced by: 51782 Based on review of restraint policy and interviews, it was determined that the facility failed to ensure that hospitals must report deaths to CMS associated with the use of seclusion or restraint. Findings include: 1. During the review of the patient restraint facility policy, performed on 08/13/2025 through 08/14/2025, at 9:35 AM, there was no mention that deaths associated with patients in restraints should be reported to CMS accordingly with State Operation Manual Appendix A (Rev. 220; Issued:04/19/24) TAG A 0213 s §482.13(g)(1) & (3)(i) the hospital must report the following information to CMS by telephone, facsimile, or electronically. In an interview with the Patient Service Officer (employee #16) performed on 08/14/2025 at 9:19 AM, she indicated that she did not have a policy and procedure for reporting deaths occurs while a patient is in restraint. In an interview with the Director of Institutional Programs (employee #6) performed on 08/14/2025 at 10:00 AM, she stated that she had knowledge related to the death by restraint reports but does not have the policy available.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 51637 Based on review of documentation and staff interview performed on 08/13/2025, it was determined that the Quality Assurance Performance Improvement -QAPI program failed to correct follow up to a received complaint. (Cross Reference TAG A0750) Findings include: 1. On 08/13/2025 at 10:14AM with the institutional programs and quality director (employee #6) a relative complaint was reviewed. This relative stated that their mom, who was a patient of this hospital, was in decomposition status when was reclaimed by the funerary and was a funerary employee who told this to her. The temperatures of the body holding refrigerator in November 2024, which was the relative patient death, were up to 55 grades (º) Fahrenheit (F) . 2. On an interview with employee #6 performed on 08/13/2025 at 10:16AM she states that the QAPI program closed the complaint after multiples interviews and concluded that the facility was not incurring in failure with the care of the corpses. However, in the complaint documents review the embalmer’s report did state that the corpse had the skin condition of the upper and lower extremities with changes after death due to the progressive appearance of cadaveric phenomena. After the QAPI program closed the complaint, did not follow up with the temperatures and conditions of the body holding refrigerator. 3. On the corpse reclaim log from October to November 2024 reviewed on 08/13/2025 at 10:18AM with employee #6, it was observed that the facility had the corpses up to five (5) days in the refrigerator waiting to be claimed.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 51637 Base on review of documents and staff interview performed on 08/14/2025, it was determined that the facility failed to have a complete anesthesia program. Findings include: On an interview with anesthetist (employee #11) performed on 08/14/2025 at 9:32AM she states that the anesthesia program does not have QAPI indicators tracking, improvement project, adverse event tracking and neither personnel reunions. She also states that they do not have educations performed since November 2023.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 51829 Based on review of eleven medical staff credential files (MSCFs) and an interview with Medical Director (Employee No. 34) on August 13, 2025, at 11:50 a.m., and with Assistant Administrator (Employee No. 19) on August 14, 2025, at 10:30 a.m., it was determined that the hospital failed to ensure medical staff have an updated health certificate, cardiopulmonary resuscitation (CPR) certification, influenza vaccination, state narcotics license, and criminal background checks of 1 of the 11 medical staff members (MSCF No. 11). Findings include: 1.During the review of the credential files of eleven medical professionals, conducted on August 13, 2025, between 3:00 p.m., one of them was identified as having expired credential. a. A health certificate (05/14/2025), CPR (not provide evidence), influenza vaccination (06/2023), state narcotics license (02/28/25), and criminal background check (08/16/2022). 2. According to the “Bylaws” established at the Hospital A, personal professional qualifications are required.”

“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 interviews and medical record reviewed (RR) performed with the Nursing Director (employee #7) at the Medicine and Intensive Care unit, it was determined that the facility failed to assure that the nursing staff were planning their interventions on the plan of care according to the patient’s needs, for 2 out of 43 records reviewed. (RR # 6 and # 8). Findings include: 1. The following was identified during the review of cases who had an order for enteral feeding with Nursing Director (employee #7) of the hospital on 08/13/25 from 9:30 am till 1:55 pm: a. RR # 6 is 77 years old female patient admitted on 07/18/25 with a diagnosis of Sepsis, Pneumonia and Urinary Tract Infection. This patient had a percutaneous endoscopic gastrostomy tube (PEG) feeding tube and had an order for Peptamen AF Enteral feeding 4 bottles by bolus daily. The surveyor asks the Nursing Director (employee #7) on 08/13/25 at 10:55 am to provide evidence of the plan of care for the bolus enteral feeding procedures to ensure a safe delivery of nutrition and hydration and assess tolerance. Nursing Director (employee #7) stated on an interview on 08/13/25 from 11:10 am that facility did not have a policy for the enteral feeding by bolus administration and that nursing personnel develop and implement a plan of care who includes interventions related with general aspects of nutritional care but did not have a nurse’s plan of care that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs specific for the enteral feeding by bolus procedure. The facility failed to maintain a plan of care who address individual needs and promotes overall health and well-being with respect to enteral feeding nutrition administered by bolus. b. RR # 8 is 71 years old male patient admitted on 07/22/25 with a diagnosis of Bacteremia and Dysphagia. This patient had a nasogastric tube and had an order for Glucerna Enteral feeding 5 bottles by bolus. The surveyor asks the Nursing Director (employee #7) on 08/13/25 at 10:00 am to provide evidence of the plan of care for the bolus enteral feeding procedures who include verifying tube placement to ensure patient safety and assess tolerance. Nursing Director (employee #7) stated on an interview on 08/13/25 from 10:20 am that facility did not have a policy for the enteral feeding by bolus administration and that nursing personnel develop and implement a plan of care who includes interventions related with general aspects of nutritional care but not have a nurse’s plan of care that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs specific for the enteral feeding by bolus procedure. The facility failed to maintain a plan of care who address individual needs and promotes overall health and well-being with respect to enteral feeding nutrition administered by bolus.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 20423 Based on forty-three closed and active clinical records reviewed (R.R) from 08/12/2025 through 08/14/2025, it was determined that the facility failed to ensure that all patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedure, 5 out of 43 Records Review (RR#18, #25, #26, #27 and #28). Findings include: 1. R.R #18 is a 99-year-old female who was admitted on 08/11/2025 to the emergency room (ER) with a diagnosis of Weakness. During observation rounds in the emergency room on 12/08/2025 at 11:00 am, in cubicle #3, the patient was observed with both arms restrained. A companion was asked how long the restraint had been in place, and he indicated he did not know since he had just arrived. During the record review performed on 08/12/2025 at 3:00 PM, no evidence was found that the physician writes a complete restraint order that includes type of restraint, and parts to be restricted. No evidence was found that the nurse documented the assessment every 2 hour accordingly with 482.13(e)(10) and facility P&P. No evidence was found that the physician document in the physician’s progress notes a justification and a face-to-face assessment before restraint. 2. R.R. #25 is a 64-year-old male who was admitted on 11/16/2024 with a diagnostic of Acute Kidney Injury, Hypercalcemia, Diabetes Mellitus High Blood Pressure. The record was reviewed on 08/14/2025 at 8:48 am. The anesthesiologist failed to complete the pre anesthesia consultation due to left in blank the gastrointestinal (GI) system, the preoperative diagnosis and laboratories result as White blood Cell (WBC), Hemoglobin (Hb), Hematocrit (Hct), Platelet (Plt) and the Anesthesia Plan. Failed to complete the Anesthesia Department sheet due to the post operative diagnosis write same and do not specificity since patient was in nothing per mouth (NPO). 3. R.R. #26 is a 73-year-old female who was admitted on 11/17/2024 with a diagnostic of Right Femur Fracture. The record was reviewed on 08/14/2025 at 9:50 am. The anesthesiologist failed to document the post operative diagnosis due to the post operative diagnosis writing same. 4. R.R. #27 is a 69-year-old female who was admitted on 12/28/2024 with a diagnose Acute Nephritis Syndrome. The record was reviewed on 08/14/2025 at 10:00 am. The physician discharged summary lack of Final diagnosis. 5. R.R. #28 is a 42-year-old male who was admitted on 06/08/2025 with a diagnostic of Pneumonia and Diabetes Mellitus. The record was reviewed on 08/14/2025 at 11:25 am.”

“CONTENT OF RECORD: FINAL DIAGNOSIS CFR(s): 482.24(c)(4)(viii) [All records must document the following, as appropriate:] Final diagnosis with completion of medical records within 30 days following discharge This Standard is not met as evidenced by: 20423 Based on forty-three closed and active clinical records reviewed (R.R) from 08/12/2025 through 08/14/2025, it was determined that the facility failed to ensure that Final diagnosis with completion of medical records within 30 days following discharge for 3 out of 14 Records Review (RR#25, #26, and #27). Findings include: 1. R.R. #25 is a 64-year-old male who was admitted on 11/16/2024 with a diagnostic of Acute Kidney Injury, Hypercalcemia, Diabetes Mellitus High Blood Pressure. The record was reviewed on 08/14/2025 at 8:48 am. Patient was discharge on 01/04/2025 however, the physician discharged summary lack of Final diagnosis. 2. R.R. #26 is a 73-year-old female who was admitted on 11/17/2024 with a diagnostic of Right Femur Fracture. The record was reviewed on 08/14/2025 at 9:50 am. Patient was discharge on 01/24/2025 however, the physician discharged summary lack of Final diagnosis. 3. R.R. #27 is a 69-year-old female who was admitted on 12/28/2024 with a diagnose Acute Nephritis Syndrome. The record was reviewed on 08/14/2025 at 10:00 am. Patient was discharge on 01/07/2025 however, the physician discharged summary lack of Final diagnosis.”

“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 did not promote safe procedures to clean and disinfect kitchen pots, pans and other items, maintain equipment in good condition and maintain clean and sanitary environment to ensure food safety and compliance with health regulations. Findings include: The following was found during the observational tour of the kitchen service with kitchen manager (employee #1) of the hospital on 08/12/25 from 8:30 am till 11:55 am: 1.Pipes located under tray washing machine were observed with a broken pipe leaking water. Water is being collected in a metal cooking tray. 2. Floor located under the tray washing machine where the broken pipe is leaking water is observed with water stains and discolorations and marks left behind the surface after the water has been present subsequently dried. 3. The area where the three-compartment sink is located is observed full of pots, pans and other kitchen items. A gallon container of Clorox disinfecting bleach was observed near the three-compartment sink. 4. The surveyor asks the kitchen manager (employee #1) of the hospital on 08/12/25 at 8:45 am what type of procedure and disinfectant they use for the three-compartment sink. He stated that they use Clorox or ARREX-100, in the three-compartment sink. Employee #1was asked for the temperature and percentage of dilution use for the three-compartment sink cleaning and disinfection procedure. Employee #1 explains that kitchen personnel did not have an established policy or procedure that they use a pump ( that is 3.5 ounces ) per 5 gallons of water, if they use ARREX-100, and 1 ounce per gallon of water if they use Clorox. He was asked the temperature of the water that they use for the three-compartment sink procedure. He stated that personnel use hot water, but he does not know the exact temperature used. He also stated that kitchen does not have a written policy to establish the procedure to clean and disinfect pots, pans and other kitchen items in the three-compartment sink. The facility failed to ensure that personnel had knowledge of policies related to the three compartment sanitizing procedures and use. 5. Enteral feeding preparation room, ceiling tiles were observed with brown stains. Facility failed to ensure that kitchen environment is maintained in good condition.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 47384 Based on the observational tour in the facility with the Safety Officer (employee #21) on 08/12/2025 through 08/14/2024 from 8:30 AM to 4:00 PM, it was determined that the facility failed to ensure the condition of the physical plant and the overall hospital environment to be maintained in such a manner that the safety and well-being of patients are assured. Findings includes: 1. Mold was observed on air vents on mens and womens changing room on Surgery Department. 2. Missing air vent on womens changing room 3. Water damage observed on ceiling tiles on anesteshia station 4. One o two faucets work in the anesthisia department area . 5. Broken tile on wall of surgery room #1 6. Floor was observed in really bad shape on surgery room #1 7. Wall with sticking material on the Autoclave area. 8. Extraction vent was observed blocked by medical equipment. 9. Broken gypsumboard on cubicule of recovery. 10. Water damage observed on ceiling tiles of cubicule #5. 11. Recepticule observed un fastened from wall in dity linnen room. 12. Air conditioning (AC) vent with black mold like stain on the Ambulatory area. 13. Black mold like stains on ceiling tiles on the Emergency Room area. 14. Two (2) ultraviolet insect lamps observed in need of adhesive film change and cleaning. 15. Hand rails on medicine floor were observed loose.”

“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 a facility Safety Officer (employee #21), it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101. Findings include: The Life Safety from Fire survey was performed on August 13, 2025 from 8:30 AM till 3:30 PM with the facility Safety Officer for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS2567 form (K0211, K0223, K0225, K0271, K0281, K0291, K0293, K323, K325, K0342, K0343, K0345, K0355, K0363, K0761, K0908, K0918, K0920 and K0923).”

“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 observations made in operating rooms with the supervisor (employee #23) on 8/13/2025 through 08/14/2025 and with the director of nursing (employee # 7) on 8/12/2025 at 10:45 AM (Medicine ward), it was determined that the facility failed to ensure adequate maintenance of facility’s supplies, and equipment to ensure an acceptable level of safety and quality. Findings include: 1. During visits to the operating room area with the supervisor (employee #23) on 8/13/2025 through 08/14/2025, from 9:00 AM to 1:00 PM, the following was observed: a. The foam seal on the door of room #1 was observed to be detached. b. The base of the operating room lamp was observed to be detached. c. The C-ARM was observed to have no maintenance seal. d. A multi-plug connected to machines was observed in the endoscopy room. e. A detached air conditioning duct was observed in the secretary’s office. f. In room #3, the biological waste container was found without a lid; the lid was observed on the floor. g. Torn curtains were observed at the top of the holding area. h. A loose plug was observed in the medication room (Pyxis). i. In the holding area, it was observed that cubicles #1 and 3 had no light. j. In the recovery area, cubicles #3 and #4 were observed to have no light. k. In the outpatient area, it was observed that the nurse call system in unisex bathroom #2 was not working. l. In the outpatient area, nurse call systems were observed in cubicles #1, 2, and 3, located on the wall without patient accessibility. m. In room #1, it was observed that the lamps were separated from the acoustic panel. 51629 2. During inspection of the crash carts located in the medicine ward and interview with the director of nursing (employee #7) on 8/12/2025 at 10:45 AM, the following was found: a. Crash cart # 1 - Nine laboratory sample tubes were found with expiration dates of 06/30/25 (five blue cap tubes) and 07/31/25 (green cap tubes). b. Crash cart # 2 - Eighteen laboratory sample tubes were found with expiration dates of January 2025 (five blue cap tubes and five green cap tubes), March 2025 (five lilacs cap tubes) and May 2025 (three red cap tubes). c. Crash cart # 2 - one type E oxygen tank without meter or key to open it. The facility failed to ensure adequate maintenance of facility’s supplies, and equipment to ensure an acceptable level of safety and quality.”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 47632 2. During the evaluation of the temperature and humidity folder in the operating rooms, the sterile supply room, the medication room, the endoscopy room, the central supply room, and the serum room, it was found that the areas did not have normal levels, according to the normal parameters of temperature of 68-73 degrees° Celsius and humidity of 30-60 percent %. The interview with the operations room supervisor (employee #23) on 08/14/2025 at 9:15 AM, revealed that the facility had provided him with a new chart in July. He had no idea whether the physical plant staff had been notified of the anomaly regarding the unit’s temperature and humidity. 51637 Based on observation performed on 08/12/2025, it was determined that the facility failed to have adequate temperature and humidity control in required areas. Findings include: The Guidelines FOR DESIGN AND CONSTRUCTION of Health Care Facilities 2010 edition state that the non-refrigerated body holding area (where the refrigerator is at) must have a negative pressure monitor and a temperature of 70 to 75 degrees ( º) Fahrenheit (F). Also states that the soiled lines area must have a negative pressure monitor. 1.During the facility first tour performed on 08/12/2025 from 8:15AM to 12:00PM the following was observed: a. The body holding room area does not meet the requirements of temperatures and negative pressure. b. The soiled linen area in the holding body area and does not have negative pressure and must be placed in an individual area. c. The soiled linen area in the intensive care area with the janitor room does not have negative pressure and must be placed in an individual area.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 51782 Based on the observational tour in the Respiratory Therapy Department with the Therapy Respiratory Supervisor (employee #12) on 08/12/2025 through 08/14/2024 from 8:30 AM to 4:00 PM, 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 includes: 1. During the round made with the Therapy Respiratory Supervisor (employee #12) in the therapy respiratory department area on 08/12/2024 at 9:30 AM, the following was observed: a) On 08/12/2025 at 9:39 AM, five nasal canula for high flow oxygen therapy expired on 12/14/2023 and three expired on 01/11/2024 were observed on the medical-surgical supplies area of the respiratory therapy department. b) On 08/12/2025 at 9:50 AM, three manual resuscitators for infants expired on 02/24/2025 were observed on the medical-surgical supplies area of the respiratory therapy department. 47632 2. During observations made in the operating rooms in the company of the operating room supervisors (employee #23) and anesthesia from 08/13/2025 to 08/14/2025 from 9:00 AM to 11:00 AM, the following was found: Room #1 a. The X-ray viewer was observed to have dark spots. b. Twenty-eight Soffsilk 3.5 metric 30”75” cm expired on 05/2025. c. Anesthesia cart: -One 6.0 mm open endotracheal tube. -One Epinephrine 1milligram (mg)/1millilitre (ml) expired 05/2025. -Naloxone HCL 0.4mg/ml d. Dark spots on the ceiling of the room. e. Peeling surgical lamp. f. In room #1, it was observed that the lamps were separated from the acoustic panel. g. In room #1, it was observed that the acoustic was separated. Room #2 a. Two #5 feeding tubes expired 08/30/2024. b. Two suction hoses without packaging. c. Three 250 ml bottles of Sevofluranne were found outside the anesthesia cart. d. During a procedure performed, the surgical towel was observed tied to an IV stand. e. The nurse anesthetist ( employee #24) administered medication in two ocassions into the infusion set without first cleaning the connector with alcohol. f. There was no hand washing with soap and water and alcohol-based hand sanitizer after removing gloves following the procedure by nursing staff (employee #24), operating room technician (employees #26 and 27), and surgeon (employee #25). Room #3 a. One #5 feeding tube expired 08/30/2025. b. Arm supports from the surgical table placed in the biohazard bin. c. Leg support from the operating table placed on the floor. d. In room #3, the biological waste container was found without a lid; the lid was observed on the floor. Holding area a. Catheterization cart. -Two purple tubes (EDTA) expired 04/30/2025. -Two blue tubes expired 05/31/2025. -One open IV start kit. Surgeons’ documentation area a. Moisture was observed on the wall. Supervisor’s office a. Moisture was observed on the wall. Medication room (Pyxis) a. Acoustic staining was observed. b. Trash was observed behind the Pyxis. Sterile supply room a. Expired sterile instrument packs were 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: 51637 Based on observations, review of documentation and staff interviews performed on 08/12/2025 till 08/14/2025 it was determined that the facility failed to provide adequate infection control monitoring related to isolation rooms for contact precautions, hand washing, soiled linen room, trash cans in outdoor areas, and body holding room. Findings include: 1. During the facility first facility tour performed on 08/12/2025 from 8:15AM to 12:00PM the following was observed: a. At 8:58AM Biohazard trash cans were open. b. At 9:05AM Recycling trash cans were overflowing. 2. On an interview with the safety officer (employee #21) performed on 08/13/2025 at 9:54AM he stated that the recycling trash cans company was broke and they are in communications with the regular trash company to stablish if they can mobilize the recycled trash. The facility policy for the body holding area was review with the infection control officer (employee #9) on 08/12/2025 at 2:30PM titled: “Politica De Manejo, Monitoreo Y Disposicion De Los Cadaveres En Area Temporera “BODY HOLDING AREA”” and states that the corpse does not has to stay more than 48 hours in the area, the temperatures must maintain in optimal conditions which are 33 to 39 degrees Fahrenheit, the cleaning personnel has to notify if the temperature changes and must check the temperature twice a day. The facility agreement for the body holding area was review on 08/13/2025 at 8:56AM with the executive director (employee #33) and states that the corpses going to be move to the Hospital B morgue if there were not reclaimed in three (3) days after death. 3. During the body holding room tour performed on 08/12/2025 at 9:10AM the following was observed: a. The soiled lines were in the same room. b. The room does not have negative pressure. c. Soiled lines hampers were clogging the only hand washing faucet. d. The hand washing faucet does not have sufficient illumination due to the construction area. e. The body holding refrigerator does not meet the temperature and humidity for this type of equipment. f. There were no thermometer or humidity control in the room. g. The floor of the room was wet. h. The cleaning personnel was checking the temperature of the refrigerator once a day. 4. The temperatures register was review on 08/12/2025 at 1:57PM with employee #9 and from May 2025 to August 2025 the refrigerator temperatures were up to 60 F grades most of the days. There were no evidence infection control notification or intervention to work in this situation. 5. On 08/13/2025 at 10:14AM with the institutional programs and quality director (employee #6) a relative complaint was review. This relative stated that their mom who was patient of this hospital, were in decomposition status when were reclaimed by the funerary and were a funerary employee who told this to her. On a memorandum from CMS revised on 2018 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD) they stablish that the facilities healthcare’s has to have a vigilance water program for legionella that cultures: Hot and cold water storage tanks, Water heaters, Water-hammer arrestors, Pipes, valves, and fittings, Expansion tanks, Water filters, Electronic and manual faucets, Aerators Faucet flow restrictors, Showerheads and hoses, Centrally-installed misters, atomizers, air washers, and humidifiers, Nonsteam aerosol-generating humidifiers, Eyewash stations, Ice machines, Hot tubs/saunas, Decorative fountains, Cooling towers, Medical devices (such as CPAP machines, hydrotherapy equipment, bronchoscopes, heater-cooler units). Ref: QSO-17-30- Hospitals/CAHs/NHs REVISED 07.06.2018 6. On interview with the infection control officer (employee #9) performed on 08/12/2025 at 11:15AM she states that they do not have a vigilance water program for legionella purpose. 7. On 08/12/2025 at 1:59PM the water report was reviewed with employee #9, this report does not include bacteria culture from the ice machines. 8. On interview with the safety officer (employee #21) performed on 08/13/2025 at 9:54AM he also states that the facility does not have a vigilance water program for legionella purpose. The facility policy of isolation precautions was reviewed on 08/12/2025 at 2:08 pm with employee #9 titled “GUIAS PARA LAS PRECAUCIONES DE AISLAMIENTO” and states that employees must wear dressing gown at the entrance of contact precautions insolation rooms also the room door must be always closed. T he facility policy of MRSA patient management was reviewed on 08/12/2025 at 2:25PM with employee #9 titled: “Politica Para Identificacion Y Manejo De Pacientes Colonizados Con Staphylococcus Aureus Resistente A Meticilina (MRSA)” and states that the employees must follow contact precautions with MRSA patients always. 9. During the facility first facility tour performed on 08/12/2025 from 8:15AM to 12:00PM a registered nurse was view on intensive care area in a contact precaution room (room #8) without gown at 9:30AM. 10. During a visit of the medicine floor performed on 08/13/2025 at 10:36AM a registered nurse was view in a contact precaution room (room #219) without gown, also the room door was left open when she leaves. The patient in this room was R.R. #10 who was colonized with MRSA. The facility policy of had hygiene was review on 08/12/2025 at 2:04PM with employee #9 titled: “Política Higiene de Manos” and states that the personnel must wash their hands before and after touching a patient and before and after using gloves and this procedure must be of 40 to 60 second’s time. 11. On ambulatory surgery room tour performed on 08/14/2025 at 11:52AM a direct care nurse (employee #8) was observed putting gloves to take out a patient intravenous line without perform hand washing before. After the procedure, the nurse employed a hand washing that does not comply with the hand washing policies. CROSS REFERENCE TAG A0286 20423 12. During the Emergency Room Tours performed on 08/12/2025 from 9:00 am through 1:30 pm the following was observed: a. At 9:03 am in the triage room a hole in the wall was observed, and with the pediatric scale table with peeling paint. b. At 9:05 am in the Emergency room equipment room, wooden cabinet with screw holes in the upper and lower cabinet doors. c. At 9:13 am the medical biohazard room observed the door without lock and at 1:00 pm the door was open. d. At 9:14 am the dirty sheets room was observed with acoustic sealing with black spot. e. At 9:15 am the physician room #2 was observed with the sink cabinet with broken Formica, chair with torn vinyl, examination table mat with broken vinyl. f. At 9:17 am the wooden security counter with broken Formica. g. At 9:20 am the physician room #1 was observed with the sink cabinet with broken Formica, examination table mat with broken vinyl. h. At 9:22 am the fast-track area was observed with 7 reclining chairs, with broken vinyl. i. The sample cart of the fast track was observed with the dirty rubbers and broken drawers. . j. There are no bases next to the channeling cart. k. At 9:34 am in the syringe drawers under Omnicell machine, an open vial of 20 milliliter Lidocaine 1% is observed, unlabeled with the date and time of opening. l. At 9:34 am in the primary line drawers below the printer, a 20-milliliter vial of bacteriostatic water is observed, unlabeled with the date and time it was opened. 13. At 9:40 am the minor surgery room was observed: a. The examination table with rust. b. Canister for placing sterile gloves with tape stuck on that does not allow proper cleaning. c. Cabinets superior part was observed with broken Formica and Cabinet bottom part was observed with broken Formica and without doors, and there’s a plastic drawer with a broken bottom with clean privacy curtains. d. 5-drawer metal filing cabinet with rust and piling paint. e. 5-drawer metal filing cabinet with rust in the supervisor office. 14. At 9:56 am in the medication room observed the following: a. The refrigerator was observed with dust and rust outside. b. The refrigerator was observed with hair and medication residue in the inside. c. Four acoustics over the line’s shelves with black spot and humidity. 15. At 10:11 am the crash cart in the cardio 1 cubicle was found with sample tube expired: 4 blue tubes expired on 02/28/2025, 1 light violet tube expired on 01/31/2025. 16. At 10:24 am the crash cart in the cardio 2 cubicle was found with sample tube expired: 2 blue tubes expired on 06/30/2025, 2 blue tubes expired on 02/28/2025, 1 green tube expired on 06/30/2025. 17. At 10:28 am in the ObGyn room a. Examination table with broken vinyl on the bottom (corners). 18. At 10:36 am Cubicle 1 through cubicle 10 was observed with peeling paint on the wall. 19. At 11:10 am was observe the Matre of the stretcher locate in cubicle #4 with broken vinyl. 20. At 11:25 am, the nurse’s station counter was observing with the top broken and covered with tape. 21. At 11:40 am the pediatric crash cart in the pediatric area was found with sample tube expired: 13 blue tube expired on 09/30/2024 and 2 blue tube expired on 02/28/2025, 5 grey tube expired on 05/31/2025, 8 green tube expired on 07/31/2025, 6 light violet tube expired on 04/30/2025, 1 light violet tube expired on 11/30/2024, 2 light violet tube expired on 09/30/2024 and 2 light violet tube expired on 07/31/2025 and one 21 gauge needle expired on 04/22025. 47632 22. During the evaluation of the temperature and humidity folder in the operating rooms, the sterile supply room, the medication room, the endoscopy room, the central supply room, and the serum room, it was found that the areas did not have normal levels, according to the normal parameters of temperature of 68-73 degrees° Celsius and humidity of 30-60 percent %. The interview with the operations room supervisor (employee #23) on 08/14/2025 at 9:15 AM, revealed that the facility had provided him with a new chart in July. He had no idea whether the physical plant staff had been notified of the anomaly regarding the unit’s temperature and humidity. 51629 23. During the facility tour at the Medicine ward (performed on 08/12/2025 from 9:00 AM to 12:00 PM) the following was found: a.Three heights adjustable over bed dining table with rust on the base, located in the hallway. b. RR # 8 is a 71-year-old male who was admitted on 07/22/2025 with a diagnosis of Pressure Ulcer Sacral Region, Arterial Ischemic Stroke and Coronary By Pass Surgery. Room # 225. The patient was on a bed with rust all around, including its base and side railings. The bed was also without functional breaks mechanism. c. Isolation room # 221 with a chair in the anteroom, with broken vinyl lining. d. Linen cart with a compartment at each end for storing clean and dirty linen respectively. The facility failed to provide a clean and sanitary environment to avoid sources and transmission of infection.”

“IC PROFESSIONAL TRAINING CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iv) Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of infection prevention and control guidelines, policies, and procedures. This Standard is not met as evidenced by: 47632 Based on the interview conducted with the operating room supervisor (employee #23) on 08/13/2025, it was determined that the facility failed to ensure that staff and employees providing contracted services at the hospital were educated on infection prevention and control guidelines, policies, and procedures. Findings include: During the interview with the operations room supervisor (employee #23) on 08/13/2025 at 1:42 PM, he stated that during his time as supervisor, he had only trained staff verbally. The supervisor was unable to provide any evidence of having trained staff during 2024 to 2025.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 47632 Based on observations in the standards and procedures manual with the operating room supervisor (employee #23) on 08/13/2025 through 08/14/2025 at 9:00 to 1:00 PM, it was determined that the facility failed to ensure that surgical services met the needs and resources of the policies governing surgical care, must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. Findings include: The supervisor (employee #23) provided the facility policy, last update on 10/26/2023, “Limpieza y Desinfeccion en Sala de Operaciones” on 08/14/2025 at 9:54. The policy states on page 4 document machine parameters and safety check every 30 minutes or more often as needed but not to exceed 45 minutes. 1. The operating room supervisor (employee# 23) was unable to provide a log of the cleaning carried out in the operating rooms. During the interview with maintenance staff (employee #28) on 08/13/2025 at 1:42 PM, reported that the terminal cleaning log had not been used for approximately six to seven months. She provided the terminal cleaning log with dates from July to August 2025. According to the Centers for Disease Control and Prevention (CDC), there must be written confirmation that terminal cleaning was performed. The policy does not require maintenance staff to report cleaning in a log. 2. When the operating room policy manual was evaluated, it was found to lack specific policies for the operating room. During the interview with the operating room supervisor (employee #23) on 08/14/2025 at 9:07 AM, he mentioned that he started working at the hospital in June 2025 and is trying to get organized in the area. When he provided the operating room department policy manual, upon review, it was noted that the following policies were missing; hand washing with alcohol-based hand sanitizer, use of personal protective equipment, exposure to bloodborne pathogens, safe injection practices, and temperature and humidity in operating rooms. It was also found that the next review of the manual would be in April 2025, at which time it had not yet been updated along with several policies.”

“REQUIRED OPERATING ROOM EQUIPMENT CFR(s): 482.51(b)(3) The following equipment must be available to the operating room suites: call-in system, cardiac monitor, resuscitator, defibrillator, aspirator, and tracheotomy set. This Standard is not met as evidenced by: 47632 Based on observations made in the recovery area on 08/14/2025, it was determined that the facility failed to ensure that biomedical equipment was inspected, tested, and maintained. Findings include: 1. During the inspection carried out in the recovery area on 08/14/2025 between 9:07 a.m. and 9:10 a.m., the following was observed: a. The portable pulse oximeters located in cubicles # 5 and 7 did not have the preventive maintenance seal, indicating whether the equipment was functioning properly. b. The cardiac monitors located in cubicles # 1, 2, 3, and 7 did not have the preventive maintenance seal indicating whether the equipment was functioning properly. c. The C-ARM machine located in operating room #1 did not have the preventive maintenance seal indicating whether the equipment was functioning properly. 2. The outpatient surgery manager (employee #31) was interviewed on 08/14/2025 at 11:52 AM stated that, in the event of an emergency, the patient would have to be transferred to the recovery room, as the Emergency cart is located in that area. The outpatient surgery area does not have a emergency cart in case of emergency. During the interview with the operating room coordinator (employee #29) on 08/14/2025 at 1:15 PM, he stated that, if an emergency arose, the staff would bring the emergency cart to the outpatient surgery area. The operating room supervisor (employee #23) stated that there are no records of incidents or accidents. He added that there have been no emergencies during his time there.”

“RESPIRATORY CARE PERSONNEL POLICIES CFR(s): 482.57(b)(1) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing. This Standard is not met as evidenced by: 51782 Based on the review of documents and the interview with the Human Resources Clerk (employee #17), it was determined that the facility failed to ensure the credentials files (CF) for respiratory therapy personnel qualified to perform specific procedures. Findings include: 1.During review of five personnel credential files with the Human Resources Clerk performed on 08/13/2025 from 1:25 PM through 2:00 PM provided evidence of the following: a) One out of five credential files (C.F #4), was observed with cardiopulmonary resuscitation (CPR) certification expired on 06/2025. b) The facility failed to ensure that professional staff comply with requirements.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/14/2025 from 11:00 AM through 1:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include emerging infectious diseases. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer ( employee # 21) on 08/14/2025 at 11:30 AM it was noted that the facility failed to include emerging infectious diseases such as Influenza, Ebola, Zika Virus and others.”

“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 08/14/2025 from 11:00 AM through 1:30 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 facility’s care during and an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the facility’s Safety Officer (employee #21) on 08/14/2025 at 11:30 AM 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 08/14/2025 from 11:00 AM through 1:30 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 facility’s Safety Officer (employee #21) on 08/14/2025 at 11:30 AM it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the hospital during and after an emergency.”

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/14/2025 from 11:00 AM through 1:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to have policies and procedures describing the system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records. Findings include: During the review of the facilities Emergency Preparedness Program with the facility’s Safety Officer (employee #21) on 08/14/2025 it was noted that the EP failed to have written process for preserving patient information as required under §482.15(b)(5).”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/14/2025 at 11:00 AM through 1:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer on 08/14/2025 it was noted that the facility failed to stablished policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §482.15(b)(6).”

“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 08/14/2025 at 11:00 AM through 11:30 PM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to develop and maintain policies and procedures related with the role of the facility under a waiver declared by the Secretary in accordance with section 1135 of the Act in the provision of care and treatment. Finding includes: During the review of the facilities Emergency Preparedness Program with the facility’s Safety Officer (employee #21) on 08/14/2025 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).”

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 08/14/2025 at 11:00 AM through 11:30 PM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to implement emergency and standby power systems based on the emergency plan. Finding includes: During the review of the facilities Emergency Preparedness Program with the facility’s Safety Officer (employee #21) on 08/14/2025 it was noted that the EP failed to implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #21), it was determined that the facility failed to mantain the width of aisles or corridors serving as exit acces at least 4 feet and maintained to provide the convenient removal of nonambulatory patients 19.2.3.4, 19.2.3.5. Findings include: Approximately at 10:30 AM on 08/13/2025 an unattended linen cart, computer dispatch medication cart and engineering department equipment car were observed on both sides of corrridor reduceding exit access to three-foot six inches wide. The finding was verified by the Safety Officer at the time of the observation.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #21), it was determined that the facility failed to mantain doors with self-closing devices as required on 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8. Findings include: 1.Approximately at 10:20 AM on 08/13/2025 it was observed that the double smoke barrier doors in both corridors of the second floor (medicine department) were being held up by wooden wedges and the magnets of the automatic release system of the alarm system were not functioning. 2. Approximately at 1:20 PM on 08/13/2025 it was observed that the self-closing device on exit discharge door on the South Side Stairway was found broken. The finding was verified by the Safety Officer at the time of the observation.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #21), it was determined that the facility failed to mantain Stairways and Smokeproof enclosures used as exits in accordance with 7.2. Findings include: 1. Approximately at 1:45 PM on 08/13/2025 it was observed that South Side Stairway (Galvanized Steel Stairs) did not have antislip tape on the steps. Push bar on door to the exit discharge was found not working properly. 2. Approximately at 1:55 PM on 08/13/2025 it was observed that North Side Stairway push bar on door to de exit discharge was found not working properly. The finding was verified by the Safety Officer at the time of the observation.”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #21), it was determined that the facility failed to mantain Stairways and Smokeproof enclosures used as exits in accordance with 7.7, 19.2.7. Findings include: 1. Approximately at 1:45 PM on 08/13/2025 it was observed that South Side Stairway elevation on the floor surface from door to pathway is grater than 8 inches and there is no ramp to discharge to roadway. 2. Approximately at 1:55 PM on 08/13/2025 it was observed that North Side Stairway elevation on the floor surface is uneven troughout which could make difficult the evacuation of patients. The finding was verified by the Safety Officer at the time of the observation.”

“Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #21), the facility failed to provide emergency illumination that would operate automatically along the means of egress and failed to have the required illuminance with two lamps energized during emergencies in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA 101 Sections 19.2.8, 7.8, 7.8.1.1, 7.8.1.2, 7.8.1.4 and 7.9.2.1. Findings include: 1. No emergency lighting on exit discharge of the South Side Stairway. 2. No emergency lighting on exit discharge of the North Side Stairway. 3. Only one emergency light was observed in approximately 62 lineal feet in the Surgery area. The finding was verified by the Safety Officer at the time of the observation.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 47384 Based on observations and document review made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #21), it was determined that the facility failed to ensure emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 2012 Existing edition of the Life Safety Code of the NFPA 101 Sections 7.9. Findings include: 1. No evidence of 90 minute yearly test performed by facility. 2. No emrergency light was observed at the triage area. The finding was verified by the Safety Officer at the time of the observation.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 47384 Based on observation and interview, the facility failed to ensure exit and directional exit signs were provided and means of egress marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants in accordance with NFPA 101, 2012 Edition, Section 19.2.10.1 and 7.10. Findings include: 1. Observation and interview on 08/12/2025 at approximately 9:30 AM on the Surgery Department it was noticed that no exit sign were provided in the area stating means of egress from the area. 2. Observation and interview on 08/12/2025 at approximately 10:10 AM, Exit E, exit door discharge on the basement, there was no exit sign. 3. Observation and interview on 08/13/2025 at approximately 11:10 AM, on the basemant Conference Room, sign should be relocated in order to be apparent from all locations of the room. The finding was verified by the Safety Officer at the time of the observation.”

“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 Safety Officer (Employee #21), it was determined that the facility failed to identify and ensure free acces to emergengy shutt-off valves for medical gases. Findings include: 1. During visual inspection it was observed that zone valves were not identified for area coverage throughout the facility. 2. On 08/13/25 approximately at 9:30 AM it was observed that the emergency shut-off valves on Emergency room were blocked by medical equipmnet. The finding was verified by the Safety Officer at the time of the observation.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 47384 Based on observation and interview, it was determined that the facility failed to mantain Alcohol Based Hand Rub Dispenser (ABHR) protected in accordance with 8.7.3.1. Findings include: ABHR were found in above receptacles in the following areas: 1. Entrance of Emergency Room 2. Fast Track Area 3.Between rooms 202-203, 206-207, 212-213, 216-217 The finding was verified by the Safety Officer at the time of the observation.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 47384 Based on observation and interview, it was determined that the facility failed to maintain manual alarm boxes in accordance with NFPA72 and 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5. Findings include: 1.Observation and interviews on 08/12/2025 through 08/14/2025 on the facility it was noticed that several manual activation devices (“pull stations”) exceeded the stated height per code. The operable part of the pull station should be installed between 42 inches and 48 inches from the finished floor. This range ensures accessibility for all individuals, including those in wheelchairs. 2. No smoke detectors were observed on Surgery Rooms 1 and 2. The finding was verified by the Safety Officer at the time of the observation.”

“Fire Alarm System - Notification CFR(s): NFPA 101 Fire Alarm - Notification 2012 EXISTING Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire. 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1) This Standard is not met as evidenced by: 47384 Based on observation and interview, it was determined that the facility failed to ensure that occupant notification is provided automatically in accordance with NFPA 101, 2012 Edition, Section 9.6.3 by audible and visual signals. Findings include: Observation and interview on 08/12/2025 through 08/14/2025 revealed that there are no visual (strobe) or audible signals in public area bathrooms (main lobby and MRI waiting area). The finding was verified by the Safety Officer at the time of the observation.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 47384 Based on observation, interview and records reviewed, the facility did not ensure all devices associated with the fire alarm system were tested annually, maintain complete and accurate documentation, manufacturer’s acceptable sensitivity range and testing of the fire alarm system in accordance with the requirements of NFPA 70 2011 Edition and NFPA 72 2010 Edition, NFPA 101, 2012 LSC Edition, Section 9.7.5, 9.7.7, 9.7.8 and NFPA 25 2011 Edition. Findings include: In an interview on 08/14/2025 at approximately 11:05 AM with the Safety officer (employee #21) stated there was no itemized inspection and testing of the smoke detectors, required information including the make/model, method of testing and manufacturer’s acceptable smoke sensitivity range. The finding was verified by the Safety Officer at the time of the observation.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/12/2025 through 08/14/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #21), 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 08/12/2025 approximately at 9:10 AM it was noticed that fire extinguisher monthly inspection card was not punched after April 2025 in extinguisher located on the Endoscopy holding area. 2. On 08/13/2025 approximately at 10:30 AM a fire extinguisher was observed on the kitchen with no monthly inspection card. 3. On 08/13/2025 approximately at 11:30 AM a fire extinguisher was observed obstructed by counter on the nurses’ station on the second floor. 4. On 08/13/2025 approximately at 1:30 PM a fire extinguisher was observed obstructed by sharp container on the Laboratory. The finding was verified by the Safety Officer at the time of the observation.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire with the facility’s Safety Officer (Employee #21), it was determined that the facility failed to protect corridors at clinical floors ( doors do not latch) as required by the 2012 edition of the Life Safety Code of the NFPA Section 19.3.6.3. Findings include: During the tour for life safety from fire on 08/12/2024 through 08/13/2024 from 8:30 AM through 4:00 PM, patient’s sleeping room doors were tested it was found that patient’s sleeping rooms #200. #205, #207, #208, #211, #212,#214, #218, #220, #221, #222, #223, #224, #225, #226, #227, #228, #229, #230, #232, #234, #237 do not latch when the doors are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request. The finding was verified by the Safety Officer at the time of the observation.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/12/2025 through 08/14/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #21), it was determined that the facility failed to ensure fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (2010 NFPA 80). Findings include: 1. No written records of inspection and testing are maintained and are available for review at the moment of the survey. 2. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, were not routinely inspected as part of the facility maintenance program.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/12/2025 through 08/14/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #21), it was determined that the facility failed to ensure the gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) Findings include: No written records of the inspections and testing are maintained as required.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 08/12/2025 through 08/14/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #21), it was determined that the facility failed to ensure Essential Electrical System (EES) is maintained by conducting annual testing and three-year four-hour load bank test in accordance with the requirements of NFPA 99, 2012 Edition Section 6 and NFPA 110, 2012 Edition Section 8.4.9. Findings Include: Document review and interview on 08/14/2025 at approximately 1:05 PM the documents reviewed did not evidence monthly inspections, annual inspection last dated 07/22/2024 and no 36 month test was provided. The finding was verified by the Safety Officer at the time of the document review.”

“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 08/12/2025 through 08/14/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #21), 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 #1 on the surgery department 2. One (1) on oparation room #3 on the surgery department 3. One (1) on oparation room #4 on the surgery department 4. One (1) on Fast Track 5. One (1) on Convetional Radiology 6. One (1) on Laboratory (blood bank)”

“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 08/12/2025 through 08/14/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #21), it was determined that the facility failed to observe precautionary measures to ensure safety on the cylinder storage as requested on 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) Findings include: Unprotected cylinders were observed in the following areas: 1. A Type E oxygen tank was observed in the Institutional Program area with no cart. 2. Three (3) Type E oxygen tanks were observed directly on the floor with no stand to hold.”