Hospital Menonita Ponce

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 17959 Based on review of the State Law License regulations and the review of physicians credential files (C.F.), it was determined that the facility failed to updated personnel credential files for lack of CPR, State Narcotics License, Influenza Vaccine, Covid 19 vaccine, Health certificate and Criminal Record for 10 out of 21 credential files, (Medical staff C.F. #3, #5, #7, #8, #9, #11, #14, #15, #17 and #18 ) Findings include: 1. On 09/03/2025 at 10:10 AM till 1:00 PM during the review of the physician credential file the following was found: a. Four of twenty-one physician’s personal credentials files the did not have the C.P.R or expired. (C.F. #3, #11and #18 did not have CPR on file ) and C.F. #7 the CPR expired on 02/2024. b. One of twenty-one physician’s personal credentials files did not contain evidence of their State Narcotic License (CF#8). c. Three of twenty-one physicians ‘personal credentials files did not contain evidence of their Influenza Vaccine (CF#7, #17 and #18). d. One of twenty-one physician’s personal credentials files did not contain evidence of their Covid 19 Vaccine (CF #17). e. One of twenty-one physician’s personal credentials files did not contain evidence of their Health certificate expirated on 09/04/2025 (CF #14). f. One of twenty-one physician’s personal credentials files did not contain evidence of their Criminal record expirated on 05/27/2025 C.F #5). 51629 2.During review of 13 personnel credential files and interview with human resources director (employee # 5) performed on 09/05/2025 at 9:00 AM, the following was found: a.Four out of ten registered nurses (RN) credential files do not have up to date Influenza vaccine administration certificate or evidence of vaccination refusal: CF.# 1, # 3, #4. # 7.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 51629 Based on interviews with the Discharge Planning coordinator (employee # 32), document review and five record review (RR) performed on 09/4/2025 at 1:30 PM, it was identified that the facility failed to inform each patient of their rights, in advance of furnishing or discontinuing patient care. This deficient practice was identified in 1 out of 5 cases reviewed (RR # 64), and failed to inform each Medicare beneficiary about the “Important Medicare Message” (IM) two days or 48 hours prior to discharge to exercise their right to appeal the facility’s discharge, and failed to provide the second IM form required to be submitted 48 hours prior to discharge, the deficiency was identified on 11 out of 11 RR . Findings include: The policy named: “Mensaje Importante de Medicare” (POL-SSM-TRA-000-ESP; 02/20/2025 revision) was discussed and reviewed with the Discharge Planning Coordinator (employee # 32) on 09/04/2025 at 1:30 PM. The facility policy states that the delivery of the important message must be done upon admission and at least 3 days (72 hours) before discharge. 1. RR # 64 is a 86-year-old female Medicare beneficiary who was admitted on 09/04/2025 with a diagnosis of Stroke. The patient was transferred on 09/21/2025 to a nursing home. The clinical record did not evidence that a copy of Medicare Important Message was provided 3 days prior to the transfer. 51829 The facility’s policy and procedure related to patient or legal representative notification policies regarding patient rights to appeal discharge were reviewed on 09/03/2025, at 9:09 a.m. The policy and procedure, titled “Important Medicare Message,” establishes procedures for delivery during admissions and mandates that the Important Medicare Message must be provided to all Medicare-insured patients 72 hours prior to discharge. It was reviewed on 09/02/2025. 2. During the review of 11 records, there is no evidence of delivery of the second required message 48 hours before discharge, the Important Medicare Message. In an interview on 09/03/2025 at 1:27 pm, the Director of Institutional Programs (Employee #10) confirmed that the Important Medicare Message was not provided 48 hours before discharge. He stated that this was due to an error in interpretation.”

“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: 51829 Based on observation during the performance of a medical procedure, the Facility failed to ensure the patient’s right to physical privacy during medical treatment. Findings include: During an observation conducted on September 3, 2025, at 9:52 a.m., accompanied by the supervisor (Employee #33), the doctor (Employee #35) began removing a drain from the abdomen without drawing the curtain. 47632 2. During the observation in the waiting room on 09/03/2025, at 9:55 AM, the following was observed: a. R.R. #20 is a 55-year-old woman admitted on 09/03/2025, with cataracts in her right eye. The patient was observed in the hallway, and the registered nurse (employee # 15) was treating her without providing privacy. The patient was not in a cubicle or any area where she had privacy; all staff could see the procedure being performed by the nursing staff.”

“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: 51829 Based on the records reviewed (RR), the hospital facility failed to ensure the patient was restrained based on the patient’s rights regarding the initiation, follow-up, and monitoring by the professionals in charge of their care. (RR#70) Findings include: 1. RR#70, admitted on September 7, 2025, was placed on restrain on September 7, 2025. 64-year-old male patient with a diagnosis of Atrial Fibrillation with rapid response. According to medical orders, they indicate disorientation. a. The initial medical order is dated September 7, 2025, and the next medical order was issued by the doctor on December 7, 2025. There is no evidence of a medical order on October 7 and November 7, 2025. The nursing staff’s 2-hour follow-up monitoring and documentation of the restricted patient (September 7, October 7, 2025, and December 7, 2025) is evident. b. On 07/14/2025, the patient remains restricted, but the doctor issued the following medical order: 07/16/2025. The 2-hour nursing follow-up indicates that the patient remained restricted on 07/14, 07/15, and 07/16, 2025. c. On 07/21/2025, the patient remains restricted, but the doctor issued the following medical order: 07/23/2025. The 2-hour nursing follow-up indicates that the patient remained restricted on 07/21, 07/22, and 07/23, 2025. d. On 08/05/2025, the patient remains restricted, but the doctor issues the following medical order: 08/07/2025. The 2-hour nursing follow-up indicates that the patient remained restricted on 07/21, 07/22, and 07/23, 2025. d. Nursing order that continued to be restricted on May 8, June 8, and July 8, 2025. e. On July 8, 2025, he continued to be restricted, but the doctor issued the following medical order: October 8, 2025. This is evident in the 2-hour nursing follow-up that he continued to be restricted on July 8, August 8, September 8, and October 8, 2025. f. On August 20, 2025, he continued to be restricted, but the doctor issued the following medical order: August 31, 2025. This is evident in the 2-hour nursing follow-up that he continued to be restricted until August 19, 2025. Furthermore, the nursing notes document that he was unrestricted on August 20 and August 21, with a valid medical order. g. As of 08/20/2025, it is evident that the doctor has not issued another medical restraining order. It is evident that the doctor has no progress note related to the restraint. There is no evidence of a medical order indicating discontinuing the restraints. This is until 08/31/2025, when the medical restraining order was issued. h. From 08/20/2025 to 08/31/2025, it is evident that there are no follow-up notes for monitoring and documentation every two hours for this patient’s restraints. It is evident that on 08/19/2025, the nurse documented the restraints in the nursing note, and from 08/20/2025 to 08/21/2025, she documented that the patient was not restricted. From 08/22/2025 to 08/31/2025, it is evident that there are no follow-up or progress notes regarding the patient’s restraints.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 15884 Based on review of quality assurance activities with the Quality Assessment and Performance Improvement officer (employee #10), it was identified that the facility failed to include contracted services in the Quality Assessment and Performance Improvement (QAPI) program. Findings include: 1. During the review of the facility’s hospital-wide quality assurance activities master plan natural year 2025 with the Quality Assessment and Performance Improvement officer (employee #10) on 09/04/2025 at 9:50 am it was identified that contracted services were included as part of services to be submitted as quality indicators data in order to evaluate the performance of the services. However, there are some contracted services that are not submitting data collected based on indicators to track performance of the service. 2. Anesthesia, biomedical services, laundry, pest control and ambulances services are contracted services that are not submitting data collected based on indicators to track performance of the service. During interview on 09/04/2025 at 10:35 am Quality Assessment and Performance Improvement officer (employee #10) at 10:50 am. stated that anesthesia, biomedical services, laundry, pest control and ambulances services are contracted services that are not submitting data collected based on indicators to track performance of the service. 3. Hospital’s governing body failed to ensure that the program reflects the complexity of the hospital’s organization and services; it involves all hospital departments and services. 47632 4. During the interview with the operating room supervisor (employee #14) on 09/04/2025 at 2:43 PM, it was observed that her indicators did not include infection control . 5. During the interview with the anesthesiologist (employee #12) on 09/05/2025 at 8:48 AM, he stated that indicators for anesthesia are not performed and does not participate in quality meetings.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 20423 Based on seventy-six records reviewed (RR), it was determined that facility failed to ensure patient medical record entries are complete, authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures related to lack of nursing progress note, lack of nurses assessment every 2 hour when patient restrain, incomplete anesthesia consent, Important Medicare Message not provided to the Medicare patient for 7 out of 76 records reviewed (RR. #8, #10, #11, #12, #13, #15, and #16). Findings include: 1. R.R. #8 is a 48 -year-old female admitted to the facility on 08/12/2025 with a diagnosis of Septic Shock, Urinary Tract Infection and discharge on 08/21/2025. During the record review performed on 09/04/2025 at 1:00 PM the following was found: a. On 8/14/2025 at 10:16 the physician places an order for restraint and renewed on 08/16/2025 at 13:51 to start at 7:00 am, on 04/17/2025 at 14:17, on 04/18/2025 at 20:44, on 08/19/2025 at 23:47 to start at 7:30 am, on 04/21/2025 at 8:38 am to start at 7:00 am. b. However the record lack of the nurse’s restraint assessment every 2 hours from 08/15/2025 on the 11-7 shift, on 08/17/2025 at 5:00 am and at 7:00 am. c. The Record provides evidence on Nurse restraint assessment every 2 hours that patient was restraint without a physician restraint order: - on 08/15/2025 at 11:00 am, at 13:00 am, 15:00, at 17:00, at 19:00, at 21:00, and at 23:00. - on 08/16/2025 at 1:00 am, at 3:00 am, and at 5:00 am. - on 08/17/2025 at 9:00 am at 11:00 am, at 13:00, at 15:00, at 17:00, at 19:00, at 21:00 and at 23:00. - on 08/18/2025 at 15:00, and at 19:00. - on 08/20/2025 at 9:00 am, at 11:00 am, at 13:00, at 15:00, at 17:00, at 19:00, at 21:00 and at 23:00. - on 08/21/2025 at 1:00 am, at 3:00 am, and at 5:00 am d. The Record lack of the nurse’s progress note on 04/07/2025 11-7, 7-3 and 3-11 shift on 04/08/2025 11-7, 7-3 and 3-11 shift, on 04/09/2025 11-7, 7-3 and 3-11 shift, on 04/10/2025 11-7, and 7-3 shift, on 04/11/2025 7-3, and 3-11 shift, on 04/12/2025 7-3 shift, on 04/14/2025 7-3, and 3-11 shift, on 04/15/2025 7-3, and 3-11 shift, on on 04/16/2025 3-11 shift. 2. R.R. #10 is a 74-year-old male admitted to the facility on 07/28/2025 with a diagnosis of Acute Coronary Syndrome and discharge on 07/30/2025. During the record review performed on 09/04/2025 at 2:45 PM the following was found: a. The record lack of the Important Medicare Message provided 48 hrs., before the discharge. b. The Anesthesia Consent lacks the type of anesthesia to be administered. 3. R.R. #11 is a 74-year-old female admitted to the facility on 06/25/2025 with a diagnosis of Acute Coronary Syndrome and discharge on 06/30/2025. During the record review performed on 09/05/2025 at 8:30 AM the following was found: a. The record lack of the Important Medicare Message provided 48 hrs., before the discharge. 4. R.R. #12 is a 50-year-old male admitted to the facility on 05/29/2025 with a diagnosis of Penile Cancer and discharge on 05/31/2025. During the record review performed on 09/05/2025 at 9:30 AM the following was found: a. The Anesthesia Consent lack of type of anesthesia to be administrated and the Anesthesiologist sign. 5. R.R. #13 is a 61-year-old male admitted to the facility on 04/21/2025 with a diagnosis of Cholecystitis and discharge on 04/22/2025. During the record review performed on 09/05/2025 at 10:00 AM the following was found: a. The History and Physical Assessment was performed by the physician on 04/01/2025, the patient surgery was on 04/21/2025, however no evidence was found that the physician updated the History and Physical Assessment. b. The internal medicine physician clearance lacks the date and hour when performed. 6. R.R. #15 is a 68-year-old female admitted to the facility on 03/03/2025 with a diagnosis of Respiratory Failure on Mechanic Ventilator, Pneumonia, Septic Shock and discharge on 03/05/2025. During the record review performed on 09/05/2025 at 11:10 AM the following was found: a. The patient son signs the Do Not Resuscitate (DNR) Order Form on 03/04/2025 at 8:18 PM, however no evidence was found that nurse documented in the nurse progress note that patient has an DNR and in the nurse’s flow sheet performed on 03/05/2025 the nurse documented that patient has a Full code when family sign DNR. b. The physician lacks to document on 03/05/202 at 12:30 pm that patient has A DNR order. 7. R.R. #16 is a 44-year-old female admitted to the facility on 07/06/2025 with a diagnosis of Sepsis, End Stage Renal Disease (ERSD), Infected Ulcer and Hypotension and patient died on 07/13/2025. During the record review performed on 09/05/2025 at 11:45 AM the following was found: a. The Anesthesia Consent performed on 07/07/2025 at 1:30 pm lack of type of anesthesia to be administrated. b. The Consent for blood or blood product transfusion lack of the risks specific to my condition and left in blank if patient have or have not made self-donation arrangements. c. The Record lack of the nurse’s progress note on 07/11/2025 3-11 shift. 47632 8. R.R #2 is a 60 year old male admitted to the facility on 07/16/2025 with T Central line placement. During the record review performed on 09/04/2025 at 2:57 PM, the following was found: a. The consent form for surgical and invasive procedures and consent for anesthesia services were not found in the patient’s record on the day of the procedure. 10. R.R #7 is a 75 year old female admitted to the facility on 03/05/2025 with a Excessive and frequent menstruation with irregular. During the record review performed on 09/04/2025 at 1:12 PM, the following was found: a. It was observed that the consent form for surgical and invasive procedures lacked the name of the physician. 9. R.R #59 is a 92 year old female admitted to the facility on 01/29/2025 with a Excessive and frequent menstruation with irregular. During the record review performed on 09/04/2025 at 3:23 PM, the following was found: a. It was noted that the consent form for surgical and invasive procedures lacked a date and time after the patient signed it.”

“CONTENT OF RECORD: UPDATED HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(B) [All records must document the following, as appropriate:] (i) Evidence of -- (B) An updated examination of the patient, including any changes in the patient’s condition, when the medical history and physical examination are completed within 30 days before admission or registration , and except as provided under paragraph (c)(4)(i)(C) of this section. Documentation of the updated examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 20423 Based on seventy-six records reviewed (RR), it was determined that facility failed to ensure patient medical record entries an updated examination of the patient, including any changes in the patient’s condition, when the medical history and physical examination are completed within 30 days before admission for 1 out of 76 records reviewed (RR. #13). Findings include: 1. R.R. #13 is a 61-year-old male admitted to the facility on 04/21/2025 with a diagnosis of Cholecystitis and discharge on 04/22/2025. During the record review performed on 09/05/2025 at 10:00 AM the following was found: a. The History and Physical Assessment was performed by the physician on 04/01/2025, the patient surgery was on 04/21/2025, however no evidence was found that the physician updated the History and Physical Assessment previously to the surgery.”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 20423 Based on seventy-six records reviewed (RR), it was determined that facility failed to ensure patient medical record entries properly executed informed consent forms for procedures and treatments specified by the medical staff for 3 out of 76 records reviewed (RR. #10, #12, and #16). Findings include: 1. R.R. #10 is a 74-year-old male admitted to the facility on 07/28/2025 with a diagnosis of Acute Coronary Syndrome and discharge on 07/30/2025. During the record review performed on 09/04/2025 at 2:45 PM the following was found: a. The Anesthesia Consent lacks the type of anesthesia to be administered. 2. R.R. #12 is a 50-year-old male admitted to the facility on 05/29/2025 with a diagnosis of Penile Cancer and discharge on 05/31/2025. During the record review performed on 09/05/2025 at 9:30 AM the following was found: a. The Anesthesia Consent lack of type of anesthesia to be administrated and the Anesthesiologist sign. 3. R.R. #16 is a 44-year-old female admitted to the facility on 07/06/2025 with a diagnosis of Sepsis, End Stage Renal Disease (ERSD), Infected Ulcer and Hypotension and patient died on 07/13/2025. During the record review performed on 09/05/2025 at 11:45 AM the following was found: a. The Anesthesia Consent performed on 07/07/2025 at 1:30 pm lack of type of anesthesia to be administrated. b. The Consent for blood or blood product transfusion lack of the risks specific to my condition and left in blank if patient have or have not made self-donation arrangements.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 15884 Based on dining observations, review of policies procedures and facility staff interview performed on 09/03/2025 through 08/28/2025 to from 9:00 am through 2:30 pm, it was determined that the facility failed to promote a safety environment at the kitchen premises. This deficiency affects 115 out of 115 patients admitted receiving services. Findings include: 1. During kitchen initial observational tour on survey on 09/03/2025 from 9:00 am through 10:00 am the following findings were identified: Inside kitchen, near food production area there is a housekeeping room who had a cleaning pool. This area had wooden shelves at the walls in which it was observed storage two motor base and one blender glass of a mixer, a yellow extension cord, one green plastic bucket, one plastic ice cooler, one cardboard box, two brooms, one sweeper-mop, one gallon of grease cutter chemical, one bottle of multipurpose cream cleaner, and one gallon of lime away chemical. Kitchen director (employee # 29 ) stated in interview on 09/03/2025 at 9:10 am that this housekeeping room should have been closed under lock and key and not to be used. Kitchen director (employee # 29 ) stated on interview on 09/03/2025 at 9:15 am that kitchen had a housekeeping outside kitchen production area, that was prepared to be used as housekeeping room. He also stated that he does not know the reason why this housekeeping room is located inside kitchen, near food production area is being used by kitchen personnel. 2. Facility failed to maintain cleaning chemicals and equipment stored in a separate area designated for their storage, apart from kitchen appliances.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 47384 Based on observations, and facility staff interview performed on 09/03/2025 through 09/05/2025 to from 8:30 AM through 4:00 PM, it was determined that the facility failed to maintain the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured. Findings include: 1. During observation of the physical environment through all three days, ceiling tiles were observed with water stains in the following areas: a) Surgery Department surgery room #6 b) Department Holding area in front of cubicle #1 c) Department Recovery area in front of cubicle #1 d) NICU e) Post operatory ward nurse’s station f) Ward treatment area g) Emergency Ward medicine room i) Ward warehouse j) Catheterization Ward holding area in front of cubicle #2 and #3 k) Stroke unit room 249 l) Radiologic Services area in front room #2 m) Radiologic Services area in front of bathroom 2. During observation of the physical environment on 09/03/2025 approximately at 8:30 AM, in the Surgery Department in operation room #6, it was noticed that a return vent had broken protection grill. 3. During observation of the physical environment on 09/03/2025 approximately at 9:00 AM, on the Surgery Department holding area, walls were observed with perforations and broken Formica. 4. During observation of the physical environment on 09/03/2025 approximately at 8:30 AM, in the Surgery Department in operation room #3, monolithic floors were observed cracks in center of room an in-plinth area. 5. During observation of the physical environment on 09/03/2025 approximately at 8:30 AM, in the Surgery Department next to “almacen de sueros” Intravenous Fluids Area, a wood board was observed covering the plinth part of the wall. 6. During observation of the physical environment on 09/04/2025 approximately at 10:30 AM, broken hand rail was observed on the Post operatory Ward.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47384 Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility’s Plant Manager and Safety Officer, it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101. Findings include: The Life Safety from Fire survey was performed from 9/03/2025 through 9/052025 from 8:00 am till 3:30 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS2567 form (K200, K211, K223, K291, K293, K342, K345, K353, K355, K363, K372, K781 and Tag K904).”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 15884 Based on observations, and facility staff interviews performed on 09/03/2025 through 09/05/2025 to from 9:30 am through 11:30 am, it was determined that the facility failed to ensure that facility and equipment is maintained to ensure an acceptable level of safety and quality. Findings include: During the radiology department survey procedures with X Rays department supervisor ( employee # 27 ) on 09/03/2025 from 9:30 am through 11:30 am the following findings were identified: 1.Radiology department defibrillator did not have the inspection label of the biomedical services. 2. Nuclear Medicine department defibrillator had a label of the inspection from the biomedical services that stated that last time equipment was inspected was in November 2024. The surveyor asked the X Rays department supervisor ( employee # 27 ) on 09/03/2025 at 11:00 am if the equipment had been inspected by the biomedical services personnel. 3. The X Rays department supervisor ( employee # 27 ) stated in interview on 09/03/2025 at 11:10 am that the equipment had been inspected. However, she does not specify the date when the inspection was performed. 4. Nuclear Medicine department supervisor ( employee # 28 ) stated in interview on 09/03/2025 from 11:55 am that the equipment had been inspected. However, she does not specify the date when the inspection was performed. 5. Facility administrator (employee # 30) was interviewed on 09/03/2025 at 2:00 pm and was asked for the inventory, certification or report of the biomedical services equipment maintenance. He stated that they had a contract with a company who perform the maintenance and certification of the equipment. 6. Facility administrator (employee # 30) was asked on 09/03/2025 at 2:20 pm who is the person in charge at the facility of verify that the biomedical services company review the status of the and perform maintenance of the required equipment. The administrator (employee # 30) stated that it was the engineering services department who is assigned to be in charge of ensure that biomedical services equipment maintenance company carry out the work for which they were contracted. 47632 7. During observations made in the preparation area on 09/03/2025, the following were found: a. At 9:01 AM, it was observed that the power cable was placed on top of the hazardous biological waste container. 8. During observations made in the preparation area with the supervisor (employee #14) on 09/03/2025, the following was found: a. At 9:01 AM, it was observed that the power cable was placed on top of the hazardous biological waste container. 9. During observations made in the Holding area with the supervisor (employee #14) on 09/03/2025, the following were found: a. At 9:07 AM, two holes were observed in cubicle 3. b. At 9:08 AM, two of the three curtains were observed to be torn. 10. During observations made in room #5 and Room #6 with the supervisor (employee #14) on 09/03/2025 at 9:55 AM to 10:45 AM, the following were found: Anesthesia supply cart, room #5 a. One 7.0 endotracheal tube was found to be open. b. One mini handle 00 expired on 04/01/2025. c. One mini handle 0 expired on 09/01/2025. d. One intubation stylet #14 expired on 01/23/2023. e. A pair of size 8.0 sterile gloves, expiring on 06/30/2025. Supplies room #6 a. Six monofilament absorbable sutures 3.0, expiry date 06/30/2025. b. One culture swab, expiry date 07/24/2025. c. Six needle electrodes 2.8, expiry date 02/27/2025. d. One #22 Foley catheter, expiry date 01/12/2024. e. Eight #16 Foley catheters, expiry date 06/28/2025. Anesthesia supply cart, room no# 6 a. Extension set with A-Plo control regulator, open and expired on 03/02/202. 11. During observations made in the recovery area with the supervisor (employee #14) on 09/03/2025 from 10:45 AM to 11:20 AM, the following were found: a. The warmer was observed without a maintenance inspection seal, expired 02/2025. b. A Saturometer was observed with an expired inspection seal, 08/2024. c. The malignant hyperthermia cart was found to be open. d. Cardiac arrest cart: i. One mini handle 0 expired 09/01/2025. ii. One oxygen tank was placed directly on the floor. 12. During observations made in the endoscopy area on 09/03/2025 at 1:35 PM, the following were found: Cardiac arrest cart: a. Two size 8.0 endotracheal tubes, expired 08/14/2025. b. EKG machine observed with inspection seal expired 03/2025. Storage: a. One Foley catheter, expired 10/30/2024. b. Four #30 Malecot Foley catheters expired 08/25/2025. c. One loading unit with DST 60 mm expired 06/30/2025. d. One loading unit with DST 80 mm expired 06/30/2025. 13. During observations made in the Sterile supply room on 09/03/2025 at 2:15 PM, the following was found: a. Four 3000-milliliter (ml) bottles of sterile irrigation water were found to have expired in 06/2025. b.Two 3000-milliliter (ml) bottles of sterile irrigation water were found to have expired in 07/2025. 14. During observations made in the anesthesia supply room on 09/03/2025 at 2:42 PM, the following was found: a. Four 8.0 mm endotracheal tubes, expired on 06/02/2025. b. One 5.5 mm endotracheal tube, expired on 02/19/2025. 15. During observations made in the delivery room with supervisor (employee #21) on 09/03/2025 at 2:50 PM, the following was found: a. Four sterile gloves, size 8.0, expiring on 05/31/2025. b. Twenty-eight chromic gut sutures, expiring on 02/28/2025. c. In the pre-delivery area, six of the six rooms do not have a nurse call system. 16. During observations made in the catheterization area with supervisor (employee #22) on 09/04/2025 at 8:32 AM, the following was found: Recovery area: a. It was observed in the recovery area that cubicles 1 to 5 did not have nurse call systems. b. In the recovery area, surgical supplies were found in cubicles 6 to 8. c. Two size 6.5 sterile gloves with an expiration date of 05/31/2025, two size 7.0 gloves with an expiration date of 08/31/2025, and two size 8.0 gloves with an expiration date of 06/30/2025 were observed in the emergency cart. The supervisor (employee #22) was interviewed on 04/09/2025 at 9:10 AM and stated that cubicles 6 to 8 were being used as temporary storage. Room #1 a. A shortage of endotracheal tubes was observed in the emergency cart. The emergency cart only had two size 7.5 endotracheal tubes. 51782 Facility policy provided by Emergency Room Supervisor (employee #1), on 09/05/2025 at 9:27 AM was reviewed. The policy was reviewed in December 2022, “Interfono (Nurse Call)”. The policy states on page 1, section 4.2 that it should be placed near the patient, even if it is not part of the bed. 17. During the round made with the Emergency Room Supervisor (employee #1) in the emergency room department performed on 09/03/2025 at 2:30 PM through 3:30 PM, the following was observed: a) The nurse call button cable was not accessible to the patient in the following rooms (OBS 05, #OBS 06, #OBS 07, #OBS 08, and #STROKE 02), which compromised patient safety. 51629 18. During nursing service survey procedures and interviews conducted with the director of nursing (employee # 7) on 09/3/2025 from 9:00 AM to 3:00 PM, the following findings were identified throughout the hospital: a. Equipment without the inspection label of the biomedical services or preventive maintenance already overdue: one EKG machine, seven medication carts, five vital signs machines, one open crib, one incubator, nine infusion pumps and three defibrillators.”

“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 Emergency Room Department, review of policies, and facility staff interviews performed on 09/03/2025 through 09/05/2025 from 8:30 AM through 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 include: Facility policy provided by Emergency Room Supervisor (employee #1), on 09/04/2025 at 8:17 AM was reviewed. The policy was reviewed in December 2024, “Lavado de Manos en Seco a Base de Alcohol (Hand Sanitizer)”. The policy states on page 1, section 2 that hand hygiene with an alcohol-based hand rub should be performed before and after contact with every patient, in section 3 before and after putting off gloves, and in section 6 after contact with a patient with intact skin (e.g., taking vital signs). 1. During observation of a procedure in the triage area of the emergency room, with the Emergency Room Supervisor (employee #1) and Assistant Director of Nursing (employee #2), the following was observed: a) On 09/03/2025 at 11:50 AM, it was observed that the registered nurse (employee #4) put on gloves to take the patient’s vital signs but did not wash his hands before and/or after interacting with the patient. 47632 2. During observations made in the operating room waiting area with the supervisor (employee # 14) on 09/03/2025 at 9:55 AM, the following was observed: a. R.R. #19 is a 60-year-old woman admitted on 09/03/2025 with cataracts in her left eye. The registered nurse (employee # 16) did not wash her hands with soap and water or hand sanitizer on two occasions after removing her gloves. b. The registered nurse (employee # 16) administered anesthetic drops to the patient in cubicle #1 and then went to administer anesthetic drops to the patient in cubicle #3. The registered nurse did not remove her gloves between treating one patient and another, nor did she wash her hands with soap and water or hand sanitizer. 3. During observations made in the operating room with the supervisor (employee no. 14) on 03/09/2025 at 10:54 AM, the following was observed: a. R. R. #20 is a 55-year-old woman admitted on 03/09/2025 with cataracts in her right eye. During the procedure in room#1, the registered nurse (employee # 17) did not wash her hands with soap and water or use hand sanitizer on three occasions after discarding her gloves and putting on new ones. At 11:22 AM, the nurse anesthetist (employee # 18) opened the medications: Zofran, Versed, and fentanyl, and removed the medications without first cleaning the rubber cap with alcohol. Throughout the procedure, the nurse anesthetist kept the same gloves on until the procedure was completed. At 11:42 AM, the operating room technician (employee #20) discarded his gloves and put on new ones without washing his hands with soap and water or using hand sanitizer. 4. During observations made in the operating room, in the catheterization area, with the supervisor (employee #22) on 04/09/2025 at 9:00 a.m., the following was observed: a. R. R. #62 is a 48-year-old woman admitted on 04/09/2025 with left heart catheterization. During the procedure in room #1, the registered nurse (employee #23) removed her gloves and put on new ones without washing her hands with soap and water or hand sanitizer. At 9:23 a.m., the nurse anesthetist (employee #18) removed the medications without first cleaning the rubber cap with alcohol. At 9:38 AM, the coordinating nurse (employee #24), after intervening with the patient, did not discard the gloves and continued to assist the circulating nurse without changing gloves.”

“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: 51782 * Based on the observational tour in the Emergency Room Department performed on 09/03/2025 through 09/05/2025 from 8:30 AM through 4:00 PM, it was determined that the facility failed to include method for preventing and infection control, including maintaining a clean and sanitary environment within the hospital. Findings include : 1. During the round made with the Supervisor (employee #1) and Assistant Director of Nursing (employee #2) in the emergency room department performed on 09/03/2025, the following was observed: a) On 09/03/2025 at 9:50 AM, in the medical and surgical supplies storage area, a plastic box containing clean sheets was found placed directly on the floor. 51629 2. During the round made throughout the hospital nursing units’ with the director of nursing (employee # 7) on 09/3/2025 from 9:00 AM to 3:00 PM, the following findings were identified: a. Medicine ward hall - a dirty linen cart with a clean linen cart next to it, almost touching it. b. Room #137-A and # 146 - A: Two IV stands with rust. There were patients in those rooms. c. Room # 152 - A and # 124-A: two heights adjustable over bed dining table with rust on the base and covered with Formica at the top, which was peeling in several places. There were patients in those rooms. d. Room # 124-A: one warming blanket machine stand with peeling paint on its base. There was a patient using the equipment. e. Room # 124-A: Wooden chair, which was peeling in several places. There was a patient in the room. f. Room # 123: A wall with a detached baseboard at the bottom, at the edge of a window. 51829 The established glove use policy September 3, 2025, at 9:00 AM, created on August 20, 2010, and revised on April 16, 2025, indicates that gloves do not replace the need for handwashing. The handwashing policy, created on January 20, 2002, and revised on October 1, 2024, clearly outlines the procedure and includes a World Health Organization (WHO) poster with the steps and a 40-60 second handwashing time. 3. During an observation conducted on September 3, 2025, at 9:43 a.m., the nurse (employee #34) entered the patient’s room wearing gloves on two occasions, performed the procedure, and then removed the gloves. On the first occasion, she did not wash her hands, and on the second occasion, she washed her hands. 4. During an observation conducted on September 3, 2025, at 9:50 a.m., the physician (employee #35) washed her hands briefly and without performing the corresponding steps. The established policy reviewed on September 3, 2025, at 10:00 AM titled Infection Control Measures, Correct Technique, and Processes in Respiratory Therapy, created on January 27, 2025, and revised on January 7, 2025, indicates that materials for providing therapy and patient supplies will be placed in a bag identified with the date. 5. During the observation process on September 3, 2025, at 10:57 a.m., patient (#36) had unlabeled equipment, and patient (#13) had equipment hanging on the wall of the oxygen tank without an identified bag. The established policy reviewed on September 3, 2025, 1:00 PM for Biomedical Waste Management, created on December 12, 2022, and revised on December 12, 2026, does not specify that each biomedical waste container has a fill limit, and if it requires collection even at unspecified periods, it will be collected. 6. During the observation process on September 3, 2025, at 1:27 p.m., in the isolation room of the Intensive Care Unit (Room #2), a biomedical waste bin was observed almost overflowing, and a bagged patient’s quilt was on the floor. 7. During the visit conducted on September 4, 2025, at 8:30 a.m., with the Infection Control Coordinator (Employee #9), the following were identified in various spaces: a. At 8:30 a.m. in the morgue, deterioration was observed. b. At 8:45 a.m. during this visit accompanied by the manager (Employee #39)., the room where all the soil sheets used in the hospital are stored lacked the equipment required to measure temperature and humidity, and it lacked negative pressure because the extractor fan was too small. c. At 9:10 a.m., in the room where the clean linen was stored, a deteriorated ceiling and boxes were observed near the ceiling. During this visit observation made accompanied by the manager (Employee #39). 47632 8. During the observation in the operating room from March 9, 2025, to April 9, 2025, from 9:00 AM to 3:30 PM, the following were found: a.Stained acoustic panels were observed in the changing areas, holding areas, hallway, nursing station, recovery room, delivery room, and catheterization room. b. Peeling paint on the edge of the lamp in room #5. c. Peeling wall corner in room #5. d. Surgical equipment cabinet with dark stains in room #6. e. Shar container filled beyond capacity in room #6. 9. During the observation conducted in the catheterization area of the supervisor’s office on 09/04/2025 at 10:00 AM, the following was found: a. A microwave, coffee maker, milk, cream, and bread were observed in the supervisor’s office. 10. During observations made in the room temperature records, the following was noted: According to the operating room unit temperature and humidity log, the following conditions must be maintained: The appropriate temperature range is 20 degrees° Celsius C to 22°C (68°Fahrenheit to 73°F). The appropriate humidity range is 30% to 60%. a. In Room #1, from January to August 2025, temperature fluctuations of up to 64.3°F below the appropriate level occurred, and staff did not take corrective action. b. In room #2, in January and August 2025, temperature fluctuations of up to 64°F below the appropriate level occurred, and staff did not take corrective action. c. In room #3, in January and August 2025, temperature fluctuations of up to 64°F below the appropriate level occurred, and staff did not take corrective action. d. In Room #4, in January and August 2025, temperature fluctuations of up to 55.3°F below the appropriate level occurred, and staff did not take corrective action. e. In Room #5, in January and August 2025, temperature fluctuations of up to 59°F below the appropriate level occurred, and staff did not take corrective action. f. In Room #6, in January and August 2025, temperature fluctuations of up to 59.9°F below the appropriate level occurred, and staff did not take corrective action. g. Lithotripsy room, in January and August 2025, temperature fluctuations of up to 61.1°F below the appropriate level occurred, and staff did not take corrective action. h. Pre induction, in January and August 2025, temperature fluctuations of up to 66°F below the appropriate level occurred, and staff did not take corrective action. i. Sterile supplies, in January and August 2025, temperature fluctuations of up to 57°F below the appropriate level occurred, and staff did not take corrective action.”

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 51829 Based on documents reviewed conducted on September 4, 2025, at 9:30 a.m. with the Infection Control Nurse (employee #9), it was determined that the facility failed to implement infection surveillance, prevention, and control policies and procedures throughout the hospital. Findings include: The development of necessary indicators for departments and units that enable infection surveillance, prevention, and control was demonstrated, but no efforts were made to integrate with the general staff and departments to implement them.”

“DELIVERY OF ANESTHESIA SERVICES CFR(s): 482.52(b) Anesthesia services must be consistent with needs and resources. Policies on anesthesia procedures must include the delineation of pre-anesthesia and post-anesthesia responsibilities. The policies must ensure that the following are provided for each patient: This Standard is not met as evidenced by: 47632 Based on observations made regarding the policies and procedures with the anesthesiologist (employee #12) on 09/05/2025 at 8:48 AM, it was determined that the facility did not ensure that the policies and procedures manual included infection prevention and control measures, indicators, and anesthesia equipment. Findings include: 1. During the review of the anesthesia policies and procedures manual with the supervisor (employee #12), a lack of standards and structure for infection prevention and control was observed, and there are no infection control and quality indicators. 2. It was observed that the anesthesia department’s policies and procedures manual has not been reviewed since 2022.”

“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 09/03/2025 through 09/5/2025 from 8:00 AM through 4:00 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 Safety Officer (employee #45) on 09/05/2025 at 1:30 PM, 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 09/03/2025 through 09/05/2025 from 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with Safety Officer (employee #45) on 09/05/2025 at 1:30 PM it was noted that the EP failed to stablished policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §428.15(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 09/03/2025 through 09/05/2025 from 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain policies and procedures related with the role of the facility under a waiver declared by the Secretary in accordance with section 1135 of the Act in the provision of care and treatment. Findings include: During the review of the facilities Emergency Preparedness Program with Safety Officer (employee #45) on 09/05/2025 at 1:30 PM it was noted that the EP failed to stablished policies and procedures 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 §418.113(b)(8).”

“Emergency Officials Contact Information CFR(s): §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 09/03/2025 through 09/05/2025 from 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain updated contact information for the following: Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance. Findings include: During the review of the facilities Emergency Preparedness Program with Safety Officer (employee #45) on 09/05/2025 at 1:30 PM it was noted that the EP failed to provide evidence of the Emergency Preparedness Communication Plan that included updated contact information for Federal, regional or local emergency preparedness staff and other sources.”

“Means of Egress Requirements - Other CFR(s): NFPA 101 Means of Egress Requirements - Other List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. 18.2, 19.2 This Standard is not met as evidenced by: 47384 The Facility failed to inspect fire doors in the means of egress and maintain documentation in accordance with the requirements of NFPA 101, 2012 Edition, and NFPA 80, Fire Doors and Other Opening Protectives. Findings include: Approximately at 10:58 AM on 09/05/2025 evidence of fire doors inspections was requested and no written document was provided. The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“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 #45) and the Engineering Department Manager (employee #46), it was determined that the facility failed to mantain the width of aisles or corridors serving as exit acces at least 4 feet and maintained to provide the convenient removal of nonambulatory patients 19.2.3.4, 19.2.3.5. Findings include: 1. Approximately at 8:37 AM on 09/03/2025 unattended stretchers and medical equipment on both sides of the operating rooms hallway were observed reduceding exit access. 2. Approximately at 11:35 AM on 09/03/2025 an unattended linen cart, regular trash can and medical equipment car were observed on both sides of corrridor reduceding exit access in hallway of the medicine Ward. 3. Approximately at 11:35 AM on 09/03/2025 an unattended linen cart, regular trash can and medical equipment car were observed on both sides of corrridor reduceding exit access in hallway of the Stroke Unit. The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire with the facility’s Safety Officer (Employee #45) and the Engineering Department Manager (employee #46), 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 8:30 AM on 09/03/2025 it was observed that the smoke barrier door in hallway in the Surgery Department did not close flush. 2. Approximately at 9:05 AM on 09/03/2025 it was observed that door on Operating Room #3 did not close flush due to the self -closing device. The finding was verified by the Safety Officer and Engineering Department Manager 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 interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #45) and the Engineering Department Manager (employee #46), 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 Zone 4 of the MRI. 2. No emergency lighting on outside Power Generator Room. 3. No emergency lighting on inside Power Generator Room 4. No emergency lighting in the general attending area of the Juana Diaz offsite location. 5. No emergency lighting in the egress pathway to outside (approx. 25 feet) area of the Juana Diaz offsite location. 6. No emergency lighting in the egress pathway to outside (approx. 10 feet) area of the Santa Isabel offsite location. The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #45) and the Engineering Department Manager (employee #46), 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 09/03/2025 at approximately 9:05 AM on the Surgery Department it was noticed that no exit sign were provided in the area stating means of egress from the area (oprating rooms #3, #4, #5). 2. Observation and interview on 09/03/2025 at approximately 10:10 AM, one exit sign was missing on the kitchen arae stating second egrees. 3. Observation and interview on 09/04/2025 at approximately 10:05 AM, no exit sign was observed on Zone 4 of the MRI to the outside of the area. 4. Observation and interview on 09/04/2025 at approximately 11:05 AM, no exit sign was observed on the outside Power Generator Room. 5. Observation and interview on 09/04/2025 at approximately 11:25 AM, no exit sign was observed on the outside Power Generator Room. 6. Observation and interview on 09/04/2025 at approximately 1:30 PM, no exit sign was observed on the Pharmacy Department. 7. Observation and interview on 09/05/2025 at approximately 8:30 AM, no exit sign was observed on interior area of the offsite location of Juana Diaz. The findings were verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire with the facility’s Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to maintain initiation devices in all areas. Findings include: 1. On 09/03/2025, approximately at 8:47 AM, smoke detector (#86) observed with no flashing light signaling operational status on Operating Room 5. 2. On 09/03/2025, approximately at 8:47 AM, smoke detector (#95) observed with no flashing light signaling operational status on Operating Room 6. 3. On 09/03/2025, approximately at 9:11 AM, in the Sterile Equipment Room of the Surgery Department, a smoke detector was observed with only the base and wire hanging ( no detection device attached). 4. On 09/03/2025, approximately at 9:20 AM, in the Lithotripsy Room, no smoke detector was observed in the area. 5. On 09/04/2025, approximately at 11:05 AM, in the Suction Pump Room, no smoke detector was observed in the area. 6. On 09/05/2025, approximately at 8:35 AM, in the offsite location of Santa Isabel, smoke detectors were observed at approximately inches of the air conditioning output vent, which may prevent the smoke detector from receiving direct smoke. The areas where this was observed were Mammography, X-rays, Densitometry, Sonography, and Waiting Room. 7. On 09/05/2025, approximately at 9:10 AM, in the offsite location of Santa Isabel, no smoke detector was observed at CT room that is being used as a warehouse. The findings were verified by the Safety Officer and Engineering Department Manager 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 record review, the facility failed to 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: 1. Fire alarm annunciator reported 3 troubles signals that were not restored to normal within 200 seconds. a) DET-PHOTO CUARTO 103 08/25/25 11:02:15 AM b) DET-PHOTO CUARTA DATA CIRUGIA MISSING c) DET-PHOTO PASILLO DIRECTOR IMAGINES 09/02/25 02:58:40 PM”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 47384 Based on observation, interview and document review, made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #45) and the Engineering Department Manager (employee #46), the facility failed to comply with Life Safety Code 2012 Edition, Section 9.7.5, 9.7.7, 9.7.8, NFPA 25, 2011 Edition 13.2.7.2. Findings include: 1.Observation and interview on September 3, 2025, at approximately 10:26 AM revealed main sprinkler riser and sprinkler gauge was not dated. Engineering Department Manager stated there was no documentation available for the five-year calibration report for this gauge and it would be replaced. 2. Observation and interview on September 3, 2025, at approximately 10:26 AM revealed Main Manual Valve on the riser was not protected by any mechanism (chain or lock). This may permit unauthorized people to close valve. 3.Observation and interview on September 3, 2025, at approximately 10:30 AM Fire Pump room door was open, and access was obstructed due to storage of paint cans and various tools. 4. Observation on September 3, 2025, at approximately 10:30 AM Fire Pump room revealed sprinkler gauge marked ‘2009’. There was no documentation available for the five-year calibration report for this gauge. 5. Observation on September 4, 2025 at approximately 11:30 AM loaded sprinklers were observed on the Emergency Ward waiting area. The findings were verified by Engineering Department Manager at the times of the observation and document review.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire with the facility’s Safety Officer (Employee #45) and the Engineering Department Manager (employee #46), 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 09/03/2025 approximately at 10:30 AM A fire extinguisher was observed blocked by paint cans in the Fire Pump Room. 2. On 09/03/2025 approximately at 11:30 AM A fire extinguisher was observed blocked by countertop on the nurses’ Station on the Medicine Department (first floor) 3. On 09/04/2025 approximately at 10:30 AM a fire extinguisher was observed blocked and should be relocated to the Pharmacy Department. 4. On 09/05/2025 approximately at 9:30 AM a fire extinguisher was observed blocked on the waiting area of the offsite facility of Juana Diaz. The findings were verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire with the facility’s Safety Officer (Employee #45) and the Engineering Department Manager (employee #46), 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 09/03/2025 through 09/05/2025 from 8:00 AM through 4:00 PM, patient’s sleeping room doors were tested it was found that patient’s sleeping rooms do not latch when the doors are closed. This can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request. First Floor : #101, #107, #109, #111, #112, #113, #115, #117, #121, #124, #125, #126, #133, #134, #137, #139, #142, #150, #151, and #152. Second floor: #241, #242, #243, #245, #255, #257, and #258 The findings were verified by the Safety Officer and Engineering Department Manager at the time of the observation.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 47384 Based on observation, interview and document review, made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #45) and the Engineering Department Manager (employee #46), the facility failed to comply with Life Safety Code 2012 Edition, Section 19.3.7.3, 8.6.7.1(1) . Findings include: Observation and interview on September 4, 2025 at approximately 9:26 AM revealed that smoke barrier doors in all facility had penetrations. At the moment of survey the Engineering Department Manager stated that they were working on the issue but at the moment only the wall between rooms #256 and #257 on the stroke unit has been repaired.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #45), Engineering Manager (employee #46), it was determined that the facility failed to maintain areas free of portable space heating devices. 18.7.8, 19.7.8 Findings include: Two (2) portable heaters were obseverd on Doctors office on the Surgery Departmet.”

“Gas and Vacuum Piped Systems - Warning System CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Warning Systems All master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable. 5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations and document review made during the survey for life safety from fire on 09/03/2025 through 09/05/2025 from 8:00 AM to 4:00 PM, it was determined that the facility failed to ensure all master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable. 5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99) Findings include: A pattern of non labeling the Medical Gas Shutoff valves was observed throughout the facility.”