Centro Medico Wilma N Vazquez

“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: 15884 Based on the review of forty-three personnel credential files and eight medical faculty credential files (CF), six kitchen personnel credential, three ambulatory physical therapist, nine radiology and nuclear medicine credential and nine respiratory therapist credential files (RTCF) , it was determined that the facility failed to ensure that professional staff comply with federal, state, and local laws to keep current personnel qualifications updated. This deficient practice was identified in 34 out of 78 personnel credential files reviewed. Findings include: During employee credential files review on 08/19/2025 through 08/21/2025 from 1:30 pm to 3:30 pm the following was found: 1. Six out of six credential files reviewed of kitchen personnel, including administrative dietitian, do not have evidence of an updated Annual Evaluation. 2. Three out of three credential files reviewed by the ambulatory physical therapy department, including physical therapy director of services, do not have evidence of an updated Annual Evaluation. 3. Nine out of nine credential files reviewed of the radiology, and nuclear Medicine department director of services do not have evidence of an updated Annual Evaluation. During an interview on 08/20/2025 at 1:15 pm the human resources coordinator stated that since December 2024 the facility has been in the process of reorganizing all services including human resources department. She explains that this reorganization includes appointing new personnel to human resources department, that are going to be in charge of redesigning and standardizing the instrument for personnel evaluation of all hospital personnel. She stated that when human resources finish the process, they proceed to evaluate all personnel. She stated that the purpose of the redesign is that this process is more efficient and effective. 20423 4. Four out of nine Respiratory Therapist Credential File (RTCF) reviewed do not have evidence of an updated Influenza Vaccine. RTCF # 3, #4, #7, and #9. 5. Three out of nine Respiratory Therapist Credential File (RTCF) reviewed do not have evidence of an updated Annual Evaluation. RTCF 2, #6 and #9. 6. Three out of nine Respiratory Therapist Credential File (RTCF) reviewed do not have evidence of an updated Annual Evaluation. RTCF 2, #6 and #9. 51629 7. One out of eight medical faculty credential files do not have up to date health certificate: CF.# 7. 8. One out of eight medical faculty credential files do not have evidence of recruitment through a professional services contract: CF# 5. 9. One out of five registered nurse anesthetists’ credential files do not have up to date Influenza vaccine administration certificate or evidence of vaccination refusal: CF.# 2. 10. One out of five registered nurse anesthetists credential files do not have up to date health certificate: CF.# 3. 11. One out of eight operating room nursing credential files do not have up to date basic life support course (BLS): CF.# 2. 12. Two out of eight operating room nursing credential files do not have up to date health certificates: CF.# 2, # 4. 13. One out of eight operating room nursing credential files do not have up to date criminal record certificate. The latest certificate is dated 08/06/2024: CF# 5. 14, One out of three operating room technicians (ORT) credential files do not have up to date health certificate: CF.# 1. 15. One out of twelve registered nurses (RN) credential files do not have up to date basic life support course (BLS): CF.# 8. 16. One out of twelve registered nurses (RN) credential files do not have up to date Influenza vaccine administration certificate or evidence of vaccination refusal: CF.# 2, contract employee. 17. One out of twelve registered nurses (RN) credential files do not have up to date chickenpox vaccine administration certificate or evidence of vaccination refusal: CF.# 2, contract employee. 18. One out of twelve registered nurses (RN) credential files do not have up to date health certificate: CF.# 2, contract employee. The facility failed to ensure that professional staff and medical faculty comply with federal and state laws.”

“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 sixteen (16) record reviewed (R.R) related to the important message of Medicare, 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 12 out of 16 close records reviewed (RR) (RR. #17, 18, 19, 55, 56, 57, 58, 59, 61, 62, 63, and 64). Findings include: Facility policy and procedure related to Internal Protocol: Compliance with the Important Medicare (IM) Message and Livanta’s Role as QIO were reviewed on 08/21/2025 at 1:00 pm. 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 in-patient 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. 1.R.R. #17 is an 86-year-old male who was admitted on 02/12/2025 with a diagnostic of Acute Prostatitis. The record was reviewed on 08/21/2025 at 10:50 am. The patient was discharged home on 02/17/2025. The Important Message from Medicare was provided upon admission on 02/12/2025, however the two days prior discharge Important Message from Medicare was not provided. 2. R.R. #18 is an 86-year-old female who was admitted on 03/14/2025 with a diagnostic of Acute Cystitis. The record was reviewed on 08/21/2025 at 11:05 am. The patient was discharge home on 03/16/2025. The Important Message from Medicare was provided upon admission on 03/14/2025, however the two days prior discharge Important Message from Medicare was not provided. 3. R.R. #19 is an 84-year-old male who was admitted on 04/15/2025 with a diagnostic of Prostatitis. The record was reviewed on 08/21/2025 at 11:20 am. The patient was discharged home on 04/21/2025. The Important Message from Medicare was provided upon admission on 04/15/2025, however the two days prior discharge Important Message from Medicare was not provided. 4. R.R. #61 is an 88-year-old female who was admitted on 06/30/2025 with diagnostic of Lower Left Ulcer. The record was reviewed on 08/21/2025 at 11:45 am. The patient was discharged home on 07/23/2025. The Important Message from Medicare was provided upon admission on 06/30/2025, however the two days prior discharge Important Message from Medicare was not provided. 5. R.R. #62 is a 75-year-old male who was admitted on 07/29/2025 with a diagnostic of Chronic Obstructive Pulmonary Disease (COPD). The record was reviewed on 08/21/2025 at 11:55 am. The patient was discharged home on 08/05/2025. The Important Message from Medicare was provided upon admission on 07/29/2025, however the two days prior discharge Important Message from Medicare was not provided. 6. R.R. #63 is a 94-year-old male who was admitted on 08/04/2025 with a diagnostic of Cellulitis Left Lower Limb. The record was reviewed on 08/21/2025 at 12:05 pm. The patient was discharged home on 08/06/2025. The Important Message from Medicare was provided upon admission on 08/04/2025, however the two days prior discharge Important Message from Medicare was not provided. 7. R.R. #64 is an 83-year-old male who was admitted on 08/17/2025 with a diagnostic of Urine Tract Infection (UTI). The record was reviewed on 08/21/2025 at 12:15 pm. The patient was discharge home on 08/20/2025. The Important Message from Medicare was provided upon admission on 08/17/2025, however the two days prior discharge Important Message from Medicare was not provided. 51629 8. The policy named: “Evaluación de Estimado Social y Planificación de Alta” (WNV-TSOC, 09/2023 revision) was discussed and reviewed with the Discharge Planning Coordinator (employee # 2) on 08/20/2025 at 2:30 PM. The facility policy states that a discharge planning assessment must be performed 48 hours after admission, but it does not indicate the delivery of the important Medicare message at least 2 days before discharge. a. RR # 55 is a 90-year-old female Medicare beneficiary who was admitted on 05/29/2025 with a diagnosis of Chronic kidney disease Stage 3, Hyponatremia, Hypomagnesemia and Urinary Tract Infection. The patient was discharged home on 06/04/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to discharge. b. RR # 56 is a 68-year-old female Medicare beneficiary who was admitted on 05/29/2025 with a diagnosis of Sepsis, Status Post Total Left Knee Replacement. The patient was transferred to a skill nursing facility on 06/03/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to transfer. c. RR # 57 is a 53-year-old male Medicare beneficiary who was admitted on 03/02/2025 with a diagnosis of Left Inguinal Abscess. The patient was discharge home on 03/13/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to discharge. d. RR # 58 is an 83-year-old female Medicare beneficiary who was admitted on 07/03/2025 with a diagnosis of Third-Degree Burn of Left Hand. The patient was transferred to a US hospital facility on 08/13/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to the transfer. e. RR # 59 is a 76-year-old male Medicare beneficiary who was admitted on 07/25/2025 with a diagnosis of Medication Intoxication, Suicide Attempt, Major Depression. The patient was transferred to another hospital facility on 08/12/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to the transfer. The facility failed to inform each patient of their rights to appeal 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: 20423 Based on records reviewed (R.R), Do Not Resuscitate (DNR) Policies and Procedures, it was determined that the facility failed to ensure that patients or their representatives formulate advance directive and comply with these directives related to written DNR or “Do Not Intubate” (DNI) orders in accordance to the patient’s signed consent for DNR or DNI for 2 out of 2 records reviewed for DNR compliance (R.R #3 and #60). Findings include: Facility Policies and Procedure (P&P) related to Advance Directives was review on 08/19/2025 at 1:00 pm. 1. R.R #3 is a 79-year-old female who was admitted on 08/13/2025 with a diagnosis of Complete Small Bowel Obstruction. On 08/19/2025 at 2:35 PM the record was reviewed with the Institutional Programs Director (employee #9). It was found that the patient signed a DNR consent on 08/14/2025 did not have the time. Evidence was found of the physician’s written DNR order on 08/15/2025 at 3:33 AM. There is difference on date from the DNR consent and the DNR order. No evidence was found in the physician progress note of the justification for the DNR and patient or relative orientation. Nurses progress note, Nurses flow sheet and Plan of care were reviewed on 08/19/2025 at 2:35 PM and the following were found: a.The nurse failed to document the activation of the plan of care for DNR. b. On 08/14/2025, the nurse failed to document in the nurse’s progress note that patient sign a DNR consent, on 11-7 shift, c. On 08/15/2025 the nurse failed to document in the nurse’s progress note and in the flow sheet that patient continues with DNR on the shift 3-11, and 11-7. d. On 08/16/2025, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR on the 3-11 shift. e. On 08/17/2025, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR on shift (7-3,and 3-11). f. On 08/18/2025, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR on the 3-11 shift. 2. R.R #60 is a 97-year-old female who was admitted on 08/12/2025 with a diagnosis of Sepsis, Hypotension, Leukocytosis. On 08/19/2025 at 2:50 PM the record was reviewed with the Institutional Programs Director (employee #9). It was found that the patient signed a DNR consent on 08/12/2025 did not have the hour. Evidence was found of the physician’s written DNR order on 08/12/2025 at 5:12 AM. Evidence was found in the physician progress note that physician writes that family signed DNR code paper, however no evidence was found of the justification for the DNR and patient or relative orientation. Nurses progress note, Nurses flow sheet and Plan of care were reviewed on 08/19/2025 at 2:35 PM and the following were found: a. The nurse failed to document the activation of the plan of care for DNR. b. On 08/13/2025, the nurse failed to document in the nurse’s progress note that patient sign a DNR consent, on 11-7 shift, c. On 08/14/2025 the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR on the shift 11-7. d. On 08/15/2025, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR on the 3-11 shift. e. On 08/17/2025, the nurse failed to document the nurse’s progress note and in the flow sheet that patient continues with DNR on shift 3-11 and 11-7. f. On 08/18/2025, the nurse failed to document in the nurse progress note and in the flow sheet that patient continues with DNR on the 3-11 shift.”

“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: 20423 Based on five records reviwed (RR), review of restraint policy and procedure (P&Ps), review of Mandatory Nursing Activities, it was determined that facility failed to ensure that Staff assess and monitor a patient’s condition on an ongoing basis to ensure that the patient is released from restrain at the earliest possible time, patients be free from restraint for 5 out of 5 patients in restraint. (RR #1, # 2, 16, 42, and #65). Findings include: The Facility Restraint policy and procedure reviewed on 08/19/2025 at 1:30 PM. 1. R.R. #1 is a 57-year-old male admitted to the facility on 08/05/2025 with a diagnosis of Altered Mental Status Secondary to Coma, Hepatic Encephalopathy and Seizure Disorder. During the record review performed on 08/19/2025 at 11:00 AM the following was found: a. On 08/06/2025 at 19:43 PM the physician telephonic order ordered soft restraint continue started at 19:45 due to intubated, soft limb, right and left upper extremity. However, the physician’s telephonic order does not specify the time to be restricted, the physician did not countersign the telephonic order. This order was the initial restraint order according to the medical record. The physician failed to perform comprehensive individual patient assessment before restraining the patient. The Registered Nurse (RN) failed to perform the patient assessment every 2 hours. The Nurse failed to document the patient or caregiver orientation related to restraint and provide to patient caregiver the restraint consent. The RN failed to activate the restraint plan of care on 08/06/2025 at 19:43 when the restraint started. b. On 08/06/2025 at 19:43 pm the physician performed another telephonic order for restraint to start on 08/07/2025 at 19:45 due to intubated, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. On 08/07/2025 at 9:22 am the order of 08/06/2025 was reviewed. On 08/08/2025 at 11:32 am the order of 08/06/2025 was renewed in the same order. c. On 08/08/2025 at 11:31 am the physician performed another telephonic order for soft restraint continue to start on 08/08/2025 at 11:32 due to intubated, soft limb, right and left upper extremity. However, the physician’s telephonic order not specified the time to be restricted, the physician did not countersign the telephonic order. On 08/09/2025 at 19:42 the order of 08/08/2025 was reviewed. On 08/12/2025 at 2:44 am the order of 08/09/2025 was renewed in the same order. d. On 08/08/2025 at 11:31 am the physician performed another telephonic order for soft restraint continue to start on 08/09/2025 at 11:32 due to intubated, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. On 08/09/2025 at 19:42 the order of 08/08/2025 was reviewed. On 08/12/2025 at 2:44 am the order of 08/09/2025 was renewed in the same order. e. On 08/12/2025 at 2:44 am the physician performed another telephonic order for soft restraint continue to start on 08/12/2025 at 2:44 due to intubated, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. On 08/13/2025 at 17:51 the order of 08/12/2025 was renewed in the same order. f. On 08/12/2025 at 2:44 am the physician performer another telephonic order for soft restraint continue to start on 08/13/2025 at 2:44 am due to intubated, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. On 08/13/2025 at 17:51 the order of 08/12/2025 was renewed in the same order. g. On 08/13/2025 at 17:51 the physician performed another telephonic order for soft restraint continues to start on 08/13/2025 at 17:51 due to intubated, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. On 08/19/2025 at 08:45 am the order of 08/13/2025 was renewed in the same order. h. On 08/19/2025 at 8:45am the physician performed another telephonic order for soft restraint continue to start on 08/19/2025 at 8:45 am due to intubated, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. On 08/19/2025 at 08:45 am the order of 08/13/2025 was renewed in the same order. i. No evidence was found that the Nurse performed the patient assessment every 2 hours since 08/06/2025 through 08/19/2025. No evidence was found in nurse progress note to shift 7-3, 3-11 and 11-7 that nurse assess or document patient restraint in any note from 08/06/2025 through 08/19/2025. No evidence was found that nurses activate and renew the patient restraint plan of care from 08/06/2025 through 08/19/2025. j. The physician failed to evaluate the patient to determine if it needed or not to continue the use of restraint. k. The physician failed to place a new restraint order every 24 hours. 2. R.R. #2 is a 71-year-old male admitted to the facility on 08/08/2025 with a diagnosis of Uncontrolled Diabetes Mellitus secondary ineffective left heel and sacral ulcer. During the record review performed on 08/19/2025 at 11:40 AM it was found the following: a. On 08/08/2025 at 2:00 AM the physician telephonic order ordered soft restraint continue due to disorientation, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. This order was the initial restraint order according to the medical record. The physician failed to perform comprehensive individual patient assessment before restraint the patient. The Registered Nurse (RN) failed to perform the patient assessment every 2 hours. The Nurse failed to document the patient or caregiver orientation related to restraint and provide to patient caregiver the restraint consent. The RN failed to activate the restraint plan of care on 08/08/2025 at 2:00 AM when the restraint started. b. On 08/09/2025 at 2:00 am the physician performed another telephonic order for soft restraint continue due to disorientation, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. c. On 08/12/2025 at 2:00 am the physician performed another telephonic order for continue soft restraint due to disorientation, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specified the time to be restricted, the physician did not countersign the telephonic order. d. On 08/13/2025 at 2:00 am the physician performed another telephonic order for soft restraint continue due to disorientation, soft limb, right and left upper extremity. However, the physician telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. e. On 08/19/2025 at 2:00 am the physician performed another telephonic order for soft restraint continue due to disorientation, soft limb, right and left upper extremity. However, the physician telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. f. However, no evidence was found that the Nurse performed the patient assessment every 2 hours since 08/08/2025 through 08/19/2025. No evidence was found in nurse progress notes to shift 7-3, 3-11 and 11-7 that nurse assess or document patient restraint in any note from 08/08/2025 through 08/19/2025. No evidence was found that nurses activate and renew the patient restraint plan of care from 08/08/2025 through 08/19/2025. j. The physician failed to evaluate the patient to determine if it needed or not to continue the use of restraint. k. The physician failed to place a new restraint order every 24 hours. 3. R.R. #16 is an 88-year-old male admitted to the facility on 08/16/2025 with a diagnosis of Congestive Obstructive Pulmonary Disease (COPD) Exacerbation, Mild Right Pneumothorax, Interstitial Pulmonary Disease. During the record review performed on 08/19/2025 at 3:02 PM the following was found: a. On 08/19/2025 at 8:01 AM the physician telephonic order ordered soft restraint continue started at 8:15 due to disorientation, soft limb, right and left upper extremity. However, the physician telephonic order did not specify the time to be restricted. This order was the initial restraint order according to the medical record. The physician failed to perform comprehensive individual patient assessment before restraining the patient. The Registered Nurse (RN) failed to perform the patient assessment every 2 hours. The Nurse failed to document the patient or caregiver orientation related to restraint and provide to patient caregiver the restraint consent. The RN failed to activate the restraint plan of care on 08/19/2025 at 8:01am when the restraint started. b. On 08/19/2025 at 8:01 am the physician performed another telephonic order for restraint to start on 08/20/2025 at 8:15am due to disorientation, soft limb, right and left upper extremity. However, the physician telephonic order did not specify the time to be restricted. c. No evidence was found that the Nurse performed the patient assessment every 2 hours since 08/19/2025 through 08/20/2025. No evidence was found that nurses activate and renew the patient restraint plan of care from 08/19/2025 through 08/20/2025. d. No evidence was found in nurse progress note from 8/19/2025 to shift 7-3, 3-11 and 11-7 and 8/20/2025 7-3 shift that nurse assess or document patient restraint in any note. e. The physician failed to evaluate the patient to determine if it needed or not to continue the use of restraint. f. The physician failed to place a new restraint order every 24 hours. 4. R.R. #65 is a 95-year-old female admitted to the facility on 08/17/2025 with a diagnosis of Atrial Fibrillation with Rapid Ventricular Response (RVR). During the record review performed on 08/20/2025 at 9:30 AM it was found the following: a. On 08/20/2025 at 6:45 AM the physician telephonic ordered soft restraint continues due to disorientation, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. This order was the initial restraint order according to the medical record. The physician failed to perform comprehensive individual patient assessment before restraining the patient The Registered Nurse (RN) failed to perform the patient assessment every 2 hours. The Nurse failed to document the patient or caregiver orientation related to restraint and provide to patient caregiver the restraint consent. The RN failed to activate the restraint plan of care on 08/20/2025 at 6:45 AM when the restraint started. b. On 08/20/2025 at 6:45 am the physician performer another telephonic order to be started on 08/21/2025 at 6:45 am for soft restraint continue due to disorientation, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not counter-resign the telephonic order, and the order was placed the same day of the first restraint order to start one day later. c. No evidence was found that the Nurse performed the patient assessment every 2 hours since 08/20/2025 at 6:45 am. No evidence was found in nurse progress note on shift 11-7 that nurses assess or document patient restraint. No evidence was found that the nurse activates and renews the patient restraint plan of care since 08/20/2025. d. The physician failed to evaluate the patient to determine if it needed or not to continue the use of restraint. e. The physician failed to place a new restraint order every 24 hours. 5. R.R. #42 is a 79-year-old female admitted to the facility on 07/26/2025 with a diagnosis of Acute Respiratory Failure, Acute Renal Failure and Sepsis with Hypotension. During the record review performed on 08/20/2025 at 9:47 AM it was found the following: a. On 07/30/2025 at 3:35 AM the physician telephonic order ordered soft restraint continue started at 3:45 AM due to intubated, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. This order was the initial restraint order according to the medical record. The physician failed to perform comprehensive individual patient assessment before restraint the patient. The Registered Nurse (RN) failed to perform the patient assessment every 2 hours. The Nurse failed to document the patient or caregiver orientation related to restraint and provide to patient caregiver the restraint consent. The RN failed to activate the restraint plan of care on 07/30/2025 at 3:35 AM when the restraint started. b. On 07/30/2025 at 3:35 AM the physician telephonic order ordered soft restraint continue start on 07/31/2025 at 3:45 AM due to intubated, soft limb, right and left upper extremity and renewed on 08/04/2025 in the same order. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. c. On 07/31/2025 at12:25 AM the physician performed another telephonic order for soft restraint continue to start on 08/01/2025 at 3:45 AM due to intubated, soft limb, right and left upper extremity and renewed on 08/04/2025 in the same order. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. d. On 08/04/2025 at 19:29 the physician performed another telephonic order for soft restraint continue to start on 08/04/2025 at 19:29 due to intubated, soft limb, right and left upper extremity and renewed 08/06/2025 in the same order. e. On 08/06/2025 at 19:49 the physician performed another telephonic order for soft restraint continue to start on 08/07/2025 at 19:29 due to intubated, soft limb, right and left upper extremity and renewed 08/08/2025 in the same order. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. f. On 08/08/2025 at 11:46 am the physician performed another telephonic order for soft restraint continues to start on 08/08/2025 at 11:48 am due to intubated, soft limb, right and left upper extremity and renewed 08/09/2025 in the same order. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. g. On 08/09/2025 at 4:10 AM the physician performer other telephonic order for soft restraint continue to start on 08/09/2025 at 4:10 AM due to intubated, soft limb, right and left upper extremity and renewed 08/12/2025 in the same order. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. h. On 08/12/2025 at 2:53 AM the physician performed another telephonic order for soft restraint continue to start on 08/12/2025 at 2:53 am due to intubated, soft limb, right and left upper extremity and renewed 08/14/2025 in the same order. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. i. On 08/14/2025 at 22:57 the physician performs another telephonic order for soft restraint continue to start on 08/15/2025 at 2:53 am due to intubated, soft limb, right and left upper extremity and renewed 08/16/2025 in the same order. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. j. On 08/16/2025 at 18:51 the physician performed another telephonic order for soft restraint continue to start on 08/17/2025 at 2:53 am due to intubated, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. k. On 08/20/2025 at 7:31 AM the physician performed another telephonic order for soft restraint continue to start on 08/21/2025 at 7:00 am due to intubated, soft limb, right and left upper extremity. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. l. However, no evidence was found that the Nurse performed the patient assessment every 2 hours since 07/30/2025 through 08/20/2025. No evidence was found that nurses activate and renew the patient restraint plan of care from 07/30/2025 through 08/20/2025. m. Evidence was found in nurse flow sheet that patient was restrained in shift 7-3, 3-11 and 11-7, document patient restraint in all flow from 07/30/2025 through 08/20/2025. However, no restraint was placed all day from 07/30/2025 through 08/20/2025. n. The physician failed to evaluate the patient to determine if it needed or not to continue the use of restraint. o. The physician failed to place a new order for a restraint every 24 hours.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 15884 Based on review of quality assurance activities with the Institutional Program Director (employee #9), it was identified that the facility failed to include all hospital services in the Quality Assessment and Performance Improvement (QAPI) program. Findings include: 1.During the review of the facility’s hospital-wide quality assurance activities master plan natural year 2025 with the Institutional Program Director (employee #9) on 08/21/2025 at 10:15 am it was identified that some hospital services were included as part of services to be submitted as quality indicators data in order to evaluate the performance of the services and operations. However, there are some hospital services that are not submitting data collected based on indicators to track performance of the service and operations. 2. Hyperbaric chamber and wound care ambulatory service, human resources, social work, information management, risk management and patient rights are hospital services that are not submitting data collected based on indicators to track performance of the service. During an interview on 08/21/2025 at 10:05 am with the Institutional Program Director (employee #9) stated that facility begins to provide orientation to all contracted services on December 2024, in relation with QAPI program expectations and data that must be collected based on indicators to be used to track performance of the service. She also stated that facility recruit and appoint a QAPI officer in the month of May 2025 however at this moment none of the hospital services are providing data related to operations to the QAPI program. 3.Hospital’s governing body failed to 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).”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 15884 Based on review of quality assurance activities with the Institutional Program Director (employee #9), it was identified that the facility failed to include contracted services in the Quality Assessment and Performance Improvement (QAPI) program. Findings include: 1. During the review of the facility’s hospital-wide quality assurance activities master plan natural year 2025 with the Institutional Program Director (employee #9) on 08/21/2025 at 8:50 am, it was identified that contracted services are included as part of services to be submitted as quality indicators data to evaluate the performance of the services. However, there are some contracted services that are not submitting data collected based on indicators to track performance of the service. 2. Organ procurement organization, acute dialysis, anesthesia, biomedical services and laundry services are contracted services that do not submit data collected based on indicators to track performance of the service. During an interview on 08/21/2025 at 10:05 am with the Institutional Program Director (employee #9) stated that facility begin to provide orientation to all contracted services on December 2024, in relation to QAPI program expectations and data that must be collected based on indicators to be used to track performance of the service. She also stated that facility recruits and appoints a QAPI officer on the month of May 2025 however at this moment none of the contracted services are providing data to the QAPI program. 3.Hospital’s governing body failed to ensure that the program reflects the complexity of the hospital’s organization and services; it involves all hospital departments and services. 47632 4. During an interview with the head anesthesia nurse (employee# 21) on 08/20/2025 at 11:30 AM, the head anesthesia nurse presented the indicators for the period between March and July 2025. The indicators showed a lack of infection control and included a sample of ten medical records.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 47632 Based on review of policies and procedures on 08/21/2025 at 1:10 PM, it was determined that the facility failed to ensure that the Medical Staff Bylaws & Rules and Regulations did not include do not intubate (DNI) policy. Findings include: During an interview with the medical school coordinator, she mentioned that the Medical Staff By Law & Rule and Regulation was being reviewed. At that time, she was reviewing Chapter 6. 1.The absence of a do-not-intubate (DNI) policy in the medical statutes was noted.”

“APPROVAL OF MEDICAL STAFF BYLAWS CFR(s): 482.22(c)(1) [The bylaws must:] (1) Be approved by the governing body. This Standard is not met as evidenced by: 47632 Based on interview conducted and policies and procedures reviewed on 08/21/2025, it was determined that the facility failed to ensure that Medical Staff Bylaws had been approved by medical staff and the governing body. Findings include: During an interview conducted on 08/21/2025 at 1:10 PM with the medical faculty coordinator (employee #24), she stated that the Medical Staff Bylaw & Rules and Regulations were currently under review and had not yet been approved by the committee. The last revision was made in 2017.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 51637 Based on observations and interviews performed on 08/19/2025 till 08 /20/ 2025, it was determined that the facility failed to maintain adequate amount of equipment for use in preventing medication administration errors. Findings include: 1. During the Emergency Services room tour performed on 08/19/2025 till 08 /20/2025 from 8:00AM to 12:00PM accompanied by the emergency room manager (employee #7), it was observed that they have 13 patient care cubicles divided between adult and pediatric and there were only three (3) IV infusion pumps available, and they were not being used. On an interview with employee #7 performed on 08/20/2025 at 9:00AM, she stated that this type of equipment is limited in the emergency room, and its use is prioritized for pediatric and adult patients in need of high alert medications. 51629 2. During a pediatric unit round conducted on 8/21/2025 at 10:00 AM, there were six patients on the unit. Three of the patients were receiving intravenous fluids without an infusion machine. a.In room 125-A there was a 2-year-old male receiving intravenous fluids with a regular primary IV line and a manual regulator device proximal to the IV site. b. In room 127-B there was a 3-year-old female receiving intravenous fluids with a micro drops IV line. c. In room 128-A there was a 19-year-old female receiving intravenous fluids with a regular primary IV line. The director of nursing (DON) was notified about the round findings on 8/21/2025 at 10:15 AM. 3.The facility failed to promote a mechanism for precise and controlled intravenous fluid delivery, provide safety features, deliver consistent flow rates, and offer alarms to alert staff if the infusion rates changes, all contributing to improved patient safety and comfort.”

“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 sixty-five record review (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 incomplete restraint order, lack of nursing flow sheet, lack of nurses assessment every 2 hour when patient restrain, lack of countersign the physician telephonic order, incomplete surgery and anesthesia consent, respiratory therapy’s not documented , Important Medicare Message not provided to the Medicare patient for 9 out of 9 records reviewed ( RR#17, 18,19, 20, 22, 61, 62, 63, and 64) and incomplete records 14 out of 65 ( RR #1, #2, #3, #4, #5, #8, #9, #10, #11, #12, , #16, #42, #60, and #65). Findings include: The Facility Restraint policy and procedure reviewed on 08/19/2025 at 1:30 PM. 1. R.R. #1 is a 57-year-old male admitted to the facility on 08/05/2025 with a diagnosis of Altered Mental Status Secondary to Coma, Hepatic Encephalopathy and Seizure Disorder. During the record review performed on 08/19/2025 at 11:00 AM the following was found: a. Physician telephonic order for restraint not counter signed on 08/06/2025 at 19:43, on 08/08/2025 at 11:31 am, on 08/08/2025 at 11:31 am, on 08/12/2025 at 2:44 am, on 08/12/2025 at 2:44 am, on 08/13/2025 at 17:51, on 08/19/2025 at 8:45am. b. Physician telephonic order for restraint was incomplete lack of time to be restraint on 08/06/2025 at 19:43, on 08/08/2025 at 11:31 am, on 08/08/2025 at 11:31 am, on 08/12/2025 at 2:44 am, on 08/12/2025 at 2:44 am, on 08/13/2025 at 17:51, on 08/19/2025 at 8:45, c. Physician failed to document the justification and patient and representative orientation related to restraint the patient. d. The nurses failed to document the assessment every 2 hours when the restraint started. e. The nurse failed to activate the restraint plan of care. f. The nurses failed to document the patient and caregiver orientation related to the restraint. g. The Permission for Patient Monitoring (Restriction) lack of date and time when patient or relative accepts to be restraint. h. The Delivery of Educational Brochure sheet lacks the patient or relative sign and Nurse sign; the sheet was not labeled with patient names. 2. R.R. #2 is a 71-year-old male admitted to the facility on 08/08/2025 with a diagnosis of Uncontrolled Diabetes Mellitus secondary infective left heel and sacral ulcer. During the record review performed on 08/19/2025 at 11:40 AM it was found the following: a. Physician telephonic order for restraint not counter signed on 08/08/2025 at 2:00 AM , on 08/09/2025 at 2:00 am, on 08/12/2025 at 2:00 am, on 08/13/2025 at 2:00 am, on 08/19/2025 at 8:46 am. b. Physician telephonic order for restraint was incomplete lack of time to be restraint on 08/08/2025 at 2:00 AM , on 08/09/2025 at 2:00 am, on 08/12/2025 at 2:00 am, on 08/13/2025 at 2:00 am, on 08/19/2025 at 8:46 am. c. Physician failed to document the justification and patient and representative orientation related to restraint the patient. d. The nurses failed to document the assessment every 2 hours when the restraint started. e. The nurse failed to activate the restraint plan of care. f. The nurses failed to document the patient and caregiver orientation related to the restraint. g. The Consent for Administration of Anesthesia, lack the name of physician oriented, lack date and hour when signed the consent. h. The Informed Consent for transfusion of blood and/or its derived products lacks reason for transfusing, and date and hour that sign the consent. 3. R.R #3 is a 79-year-old female who was admitted on 08/13/2025 with a diagnosis of Complete Small Bowel Obstruction. On 08/19/2025 at 2:35 PM the record was reviewed with the Institutional Programs Director (employee #9). It was found the following: a. The physician lacks to document in the progress note the justification for the DNR and patient or relative orientation. b. The nurse failed to document the activation of the plan of care for DNR. c. The nurse failed to document in the nurse’s progress note that patient signs DNR consent, on 08/14/2025 the 11-7 shift, on 08/15/2025 on the shift 3-11, and 11-7, on 08/16/2025, on the 3-11 shift, on 08/17/2025, on shift (7-3,and 3-11) and on 08/18/2025 on the 3-11 shift. d. Consent, not to offer cardiopulmonary resuscitation (DNR) or not to intubate (DNI) left in blank if patient authorized DNR or DNI. 4. R.R. #10 is a 53-year-old female admitted to the facility on 08/17/2025 with a diagnosis of COPD. During the record review performed on 08/20/2025 at 2:27 PM it was found the following a. The physician ordered on 08/17/2025 at 22:01 Proventil 0.83% (2.5 mg) every 2 hours, however no evidence was found of the respiratory therapist progress note documentation of the administration on 08/18/2025 at 8:00 am. b. The physician ordered on 08/18/2025 at 9:56 am to start at 1:00 pm Proventil 0.83% (25 mg) every 6 hours, however no evidence was found of the respiratory therapist progress note documentation of the administration on 08/18/2025 at 19:00, 08/19/2025 at 12:38 pm. c. The physician ordered 08/17/2025 at 18:57Atrovent 0.5 mg every 6 hours, however no evidence was found of the respiratory therapist progress note documentation of the administration on 08/18/2025 at 8:00 am and at 19:00, on 08/19/2025 at 19:00. d. No evidence was found related to the initial evaluation performed by the respiratory therapist previously to initiate the first respiratory therapy according to Respiratory therapist standard of practice. 5. R.R. #11 is a 62-year-old female admitted to the facility on 08/19/2025 with a diagnosis of Left Leg Cellulitis and Pulmonary Fibrosis. During the record review performed on 08/20/2025 at 3:00 PM it was found the following a. The physician ordered on 08/18/2025 at 22:42 Proventil 0.83% (2.5 mg) every 20 minute per 3, however no evidence was found of the respiratory therapist progress notes documentation of the administration on 08/18/2025 at 23:05, at 23:25, 23:45 . b. The physician ordered on 08/18/2025 at 22:42, Pulmicort 0.5 mg per 1, however no evidence was found of the respiratory therapist progress note documentation of the administration on 08/18/2025 at 22:42. c. The physician ordered on 08/17/2025 at 18:57Atrovent 0.5 mg every 6 hours, however no evidence was found of the respiratory therapist progress notes documentation of the administration. d. No evidence was found related to the initial evaluation performed by the respiratory therapist previously to initiate the first respiratory therapy according to Respiratory therapist standard of practice. 6. R.R. #12 is a 72-year-old female admitted to the facility on 08/17/2025 with a diagnosis of Bilateral Pneumonia. During the record review performed on 08/20/2025 at 1:00 PM it was found the following a. The physician ordered on 08/17/2025 at 1:00 AM Atrovent 0.5 milligram (mg) every 6 hours, however no evidence was found of the respiratory therapist progress note documentation of the administration on 08/17/2025 at 19:00, on 08/18/2025 at 19:00. b. The physician ordered on 08/16/2025 at 5:00 AM Xopenex 0.63 mg every 4 hours, however no evidence was found of the respiratory therapist progress note documentation of the administration on 08/19/2025 at 19:00. c. No evidence was found related to the initial evaluation performed by the respiratory therapist previously to initiate the first respiratory therapy according to Respiratory therapist standard of practice. 7. R.R. #16 is an 88-year-old male admitted to the facility on 08/16/2025 with a diagnosis of Congestive Obstructive Pulmonary Disease (COPD) Exacerbation, Mild right pneumothorax, Interstitial Pulmonary Disease. During the record review performed on 08/19/2025 at 3:02 PM the following was found: a. Physician telephonic order for restraint not counter signed on 08/19/2025 at 8:01 AM, on 08/19/2025 at 8:01 to start on 08/20/2025 at 8:15am. b. Physician telephonic order for restraint was incomplete lack of time to be restraint on 08/19/2025 at 8:01 AM, on 08/19/2025 at 8:01 to start on 08/20/2025 at 8:15. c. Physician failed to document the justification and patient and representative orientation related to restraint the patient. d. The nurses failed to document the assessment every 2 hours when the restraint started. e. The nurse failed to activate the restraint plan of care. f. The nurses failed to document the patient and caregiver orientation related to the restraint. g. The Consent for Administration of Anesthesia, lack the name of physician oriented, type of anesthesia, lack date and hour when signed the consent. h. The Informed Consent for transfusion of blood and/or its derived products lack of reason for transfusing, and date and hour that sign the consent. 8. R.R. #42 is a 79-year-old female admitted to the facility on 07/26/2025 with a diagnosis of Acute Respiratory Failure, Acute Renal Failure and Sepsis with Hypotension. During the record review performed on 08/20/2025 at 9:47 AM it was found the following: a.The physician telephonic order for restraint not counter signed on 07/30/2025 at 3:35 AM the physician telephonic ordered soft restraint continue started at 3:45 AM, On 07/30/2025 at 3:35 AM the physician telephonic ordered soft restraint continues start on 07/31/2025 at 3:45 AM, On 07/31/2025 at12:25 AM the physician performed another telephonic order for soft restraint continue to start on 08/01/2025 at 3:45 AM, On 08/04/2025 at 19:29 the physician performs another telephonic order for soft restraint continue to start on 08/04/2025 at 19:29, On 08/06/2025 at 19:49 the physician performed another telephonic order for soft restraint continue to start on 08/07/2025 at 19:29, on 08/08/2025 at 11:46 am the physician performed other telephonic order for soft restraint continue to start on 08/08/2025 at 11:48 am, On 08/09/2025 at 4:10 AM the physician performed another telephonic order for soft restraint continue to start on 08/09/2025 at 4:10 AM, on 08/12/2025 at 2:53 AM the physician performed another telephonic order for soft restraint continue to start on 08/12/2025 at 2:53 am, On 08/14/2025 at 22:57 the physician performed another telephonic order for soft restraint continue to start on 08/15/2025 at 2:53 am, on 08/16/2025 at 18:51 the physician perform another telephonic order for soft restraint continue to start on 08/17/2025 at 2:53 am, On 08/20/2025 at 7:31 AM the physician performs another telephonic order for soft restraint continue to start on 08/21/2025 at 7:00 am. b. Physician telephonic order for restraint was incomplete lack of time to be restraint. c. Physician failed to document the justification and patient and representative orientation related to restraint the patient. d. The nurses failed to document the assessment every 2 hours when the restraint started. e. The nurse failed to activate the restraint plan of care. f. The nurses failed to document the patient and caregiver orientation related to the restraint. 9. R.R #60 is a 97-year-old female who was admitted on 08/12/2025 with a diagnosis of Sepsis, Hypotension, Leukocytosis. On 08/19/2025 at 2:50 PM the record was reviewed with the Institutional Programs Director (employee #9). It was found that the patient signed a DNR consent on 08/12/2025 did not have the hour. Evidence was found of the physician’s written DNR order on 08/12/2025 at 5:12 AM. . a. The physician lacks to document in the progress note the justification for the DNR and patient or relative orientation. b. The nurse failed to document the activation of the plan of care for DNR. c. The nurse failed to document in the nurse’s progress note that patient sign a DNR consent, on 08/13/2025 the 11-7 shift, on 08/14/2025 on the shift 11-7, on 08/15/2025 on the shift 3-11, on 08/17/2025, on the 3-11and 11-7 shift, on 08/18/2025, on 3-11 shift. 10. R.R. #65 is a 95-year-old female admitted to the facility on 08/17/2025 with a diagnosis of Atrial Fibrillation with Rapid Ventricular Response (RVR). During the record review performed on 08/20/2025 at 9:30 AM the following was found: a. Physician telephonic order for restraint not counter signed on 08/20/2025 at 6:45 am the physician perform another telephonic order to be started on 08/21/2025 at 6:45 am. b. Physician telephonic order for restraint was incomplete lack of time to be restraint. c. Physician failed to document the justification and patient and representative orientation related to restraint the patient. d. The nurses failed to document the assessment every 2 hours when the restraint started. e. The nurse failed to activate the restraint plan of care. f. The nurses failed to document the patient and caregiver orientation related to the restraint. 11. During the evaluation of 9 records reviewed for the orientation of the Important message of Medicare, it was found that 9 out of 9 records reviewed the facility failed to orient the 9 patient 48 hours previous to the discharge for RR# 17, #18, #19, #20, #22, #61, #62, #63 and #64. 47632 12. R.R #4 is a 19-year-old female admitted to facility on 08/18/2025 with a diagnosis of Abdominal pain. During the record review performed on 08/20/2025 at 8:33 AM, the consent for the transfusion of blood and/or blood products was found without the date and time of the physician’s counseling. Consent for the administration of anesthesia did not specify the type of anesthesia that would be used with the patient. 13. R.R #5 is a 51-year-old male admitted to facility on 05/05/2025 with a diagnosis of Erectile Dysfunction. During the record review performed on 08/20/2025 at 9:07 AM, the consent form for anesthesia administration was found to be missing the type of anesthesia selected, the date of the consultation provided by the anesthesiologist, and the employee’s signature and time. The consent form for surgical procedures and/or special procedures was found to be missing the date of the physician’s consultation and the employee’s signature and time. Informed consent for blood and/or blood product transfusion was missing the date and time the patient signed, the name, signature, date, and time of the witness, and the date and time of the physician who provided the orientation. 14. R.R #8 is a 59-year-old male admitted to facility on 06/06/2025 with a diagnosis of Colonoscopy with hot snare and cold forceps polypectomy. During the record review performed on 08/20/2025 at 9:30 AM, it was noted that the consent form for anesthesia administration did not include the selection of the type of anesthesia. The informed consent form for blood and/or blood product transfusion did not include the name of the witness and the date and time of the physician who provided the guidance. 15. R.R #9 is a 78-year-old female admitted to facility on 08/18/2025 with a diagnosis of Colonoscopy with hot snare and cold forceps polypectomy. During the record review performed on 08/19/2025 at 2:42 PM, the consent form for surgical procedures and/or special procedures lacked the employee’s signature and time. The consent form for the administration of anesthesia lacked the date of the anesthesiologist’s briefing and the employee’s signature with the time. The informed consent form for blood and/or blood product transfusions lacked the name, signature, date, and time of the witness, as well as the date and time of the physician who conducted the briefing.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 51637 Based on observation, records and documents review and interview performed on 08/19/2025 till 08/20/2025 it was determined that the facility failed to include physician orders in patient records to follow the policies and procedures for the insolation room requirements. (Cross Reference TAG A0749), and failed to ensure that physician telephonic order be dated, timed, and authenticated promptly by the ordering practitioner for 5 out of 6 patients with restraint order RR. #1, #2, #16, #42, #65 Findings include: 1. On interview performed on 08/19/2025 at 1:45PM with the infection control coordinator (employee #8) he states that the policy and procedure for patients in isolation states that they must have a physician’s order at the time of a result or event necessary to be placed in isolation. 2 .During the record review from 9 patients on insolation room at the moment of the survey performed on 08/20/2025 from 10:15AM to 11:30AM the following was observed: a. R.R. #41 is a 68-years-old female with positive culture of MRSA since 08/08/2025 and had no physician order for insolation precautions. b. R.R. #47 is an 87-years-old male with reactive mycoplasma results from 08/04/2025, insolation precautions physician order was made on 08/05/2025 and was cancelled on 08/13/2025, however on 08/20/2025 the patient was on the insolation room. 3. Upon reviewing the infection control policies and procedures manual performed on 08/20/2025 at 2:10PM, no policy was found for the process to be followed with patients in isolation rooms. 20423 4. R.R. #1 is a 57-year-old male admitted to the facility on 08/05/2025 with a diagnosis of Altered Mental Status Secondary to Coma, Hepatic Encephalopathy and Seizure Disorder. During the record review performed on 08/19/2025 at 11:00 AM the following was found: a. On 08/06/2025 at 19:43 PM the physician telephonic order ordered soft restraint continue started at 19:45 due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. b. On 08/06/2025 at 19:43 pm the physician performed another telephonic order for restraint to start on 08/07/2025 at 19:45 due to intubated, soft limb, right and left upper extremity and the physician did not counter sign the telephonic order. c. On 08/08/2025 at 11:31 am the physician performed another telephonic order for soft restraint continue to start on 08/08/2025 at 11:32 due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. d. On 08/08/2025 at 11:31 am the physician performed another telephonic order for soft restraint continue to start on 08/09/2025 at 11:32 due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. e. On 08/12/2025 at 2:44 am the physician performer other telephonic order for soft restraint continue to start on 08/12/2025 at 2:44 due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. f. On 08/12/2025 at 2:44 am the physician performer other telephonic order for soft restraint continue to start on 08/13/2025 at 2:44 am due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. g. On 08/13/2025 at 17:51 the physician performed another telephonic order for soft restraint continue to start on 08/13/2025 at 17:51 due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. h. On 08/19/2025 at 8:45 the physician performed another telephonic order for soft restraint continue to start on 08/19/2025 at 8:45 am due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. 5. R.R. #2 is a 71-year-old male admitted to the facility on 08/08/2025 with a diagnosis of Uncontrolled Diabetes Mellitus secondary infective left heel and sacral ulcer. During the record review performed on 08/19/2025 at 11:40 AM it was found the following: a. On 08/08/2025 at 2:00 AM the physician telephonic order ordered soft restraint continue due to disorientation, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. b. On 08/09/2025 at 2:00 am the physician performed another telephonic order for soft restraint continue due to disorientation, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. c. On 08/12/2025 at 2:00 am the physician performed another telephonic order for soft restraint continue due to disorientation, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. d. On 08/13/2025 at 2:00 am the physician performed another telephonic order for soft restraint continue due to disorientation, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. e. On 08/19/2025 at 2:00 am the physician performed another telephonic order for soft restraint continue due to disorientation, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. 6. R.R. #16 is an 88-year-old male admitted to the facility on 08/16/2025 with a diagnosis of Congestive Obstructive Pulmonary Disease (COPD) Exacerbation, Mild right pneumothorax, Interstitial Pulmonary Disease. During the record review performed on 08/19/2025 at 3:02 PM the following was found: a. On 08/19/2025 at 8:01 AM the physician telephonic order ordered soft restraint continue started at 8:15 due to disorientation, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. b. On 08/19/2025 at 8:01 am the physician performed another telephonic order for restraint to start on 08/20/2025 at 8:15 due to disorientation, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. 7. R.R. #42 is a 79-year-old female admitted to the facility on 07/26/2025 with a diagnosis of Acute Respiratory Failure, Acute Renal Failure and Sepsis with Hypotension. During the record review performed on 08/20/2025 at 9:47 AM it was found the following: a. On 07/30/2025 at 3:35 AM the physician placed a telephonic order ordered soft restraint continue started at 3:45 AM due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. b. On 07/30/2025 at 3:35 AM the physician placed a telephonic order ordered soft restraint continue start on 07/31/2025 at 3:45 AM due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. c. On 07/31/2025 at 12:25 AM the physician performed another telephonic order for soft restraint continue to start on 08/01/2025 at 3:45 AM due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. d. On 08/04/2025 at 19:29 the physician performed another telephonic order for soft restraint continue to start on 08/04/2025 at 19:29 due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. e. On 08/06/2025 at 19:49 the physician performed another telephonic order for soft restraint continue to start on 08/07/2025 at 19:29 due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order f. On 08/08/2025 at 11:46 am the physician performed another telephonic order for soft restraint continue to start on 08/08/2025 at 11:48 am due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. g. On 08/09/2025 at 4:10 AM the physician performed another telephonic order for soft restraint continue to start on 08/09/2025 at 4:10 AM due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. h. On 08/12/2025 at 2:53 AM the physician performed another telephonic order for soft restraint continue to start on 08/12/2025 at 2:53 am due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. i. On 08/14/2025 at 22:57 the physician performed another telephonic order for soft restraint continue to start on 08/15/2025 at 2:53 am due to intubated, soft limb, right and left upper extremity and renewed 08/16/2025 in the same order. However, the physician’s telephonic order did not specify the time to be restricted, the physician did not countersign the telephonic order. j. On 08/16/2025 at 18:51 the physician performed another telephonic order for soft restraint continue to start on 08/17/2025 at 2:53 am due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order k. On 08/20/2025 at 7:31 AM the physician performed another telephonic order for soft restraint continue to start on 08/21/2025 at 7:00 am due to intubated, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. 8. R.R. #65 is a 95-year-old female admitted to the facility on 08/17/2025 with a diagnosis of Atrial Fibrillation with Rapid Ventricular Response (RVR). During the record review performed on 08/20/2025 at 9:30 AM it was found the following: a. On 08/20/2025 at 6:45 AM the physician’s telephonic order ordered soft restraint continue due to disorientation, soft limb, right and left upper extremity and the physician did not countersign the telephonic order. b. On 08/20/2025 at 6:45 am the physician performed another telephonic order to be started on 08/21/2025 at 6:45 am for soft restraint continue due to disorientation, soft limb, right and left upper extremity and the physician did not countersign the telephonic order.”

“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 sixty-five records reviewed (RR), it was determined that facility failed to ensure patient medical has 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 for 3 out of 65 records reviewed (RR #2, #3 and #16). Findings include: 1. The Informed Consent for blood and/or blood products transfusion was reviewed, the physician left in blank the reason for the transfusion, whether the patient authorized receiving a transfusion or not, and the date and time when the consent was signed by the patient and the physician. RR #2 and #16. 2. The Consent for Administration of Anesthesia, the doctor left blank the name of the doctor who explained, the type of anesthesia to be used, and the date and time when the consent was signed by the patient and the doctor. RR#2 and #16. 3. The Consent to not offer Cardiopulmonary Resuscitation (DNR) or to not intubate (DNI) the physician left blank if the patient authorizes the DNR/DNI order. RR. #3.”

“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 observation performed on 08/19/2025 through 08/21/2025, it was determined that the facility failed to maintain the condition of 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. Ceiling tiles with water damage on the Ulcer department waiting area. 2. Ceiling tiles with water damage on the Medical Record working area . 3. Ceiling tiles with water damage in the Surgery Department warehouse. 4. Monolithic material on wall on surgery room #D was observed with perforations 5. No nursing call was observed on endoscopy area bathroom. 6. No Monolithic material was observed on wall of CPR room on the emergency Department”

“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 (employee # 4 ) and Safety Officer (employee # 5 ), it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101. Findings include: The Life Safety from Fire survey was performed from 8/19/2025 through 8/21/2025 from 8:00 am till 3:30 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS2567 form (K211, K222, K223, K291, K293, K325, K342, K343, K355, K363, K761, K781, K902, K904, K920, K923 and Tag K931).”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 51637 Based on observation tours performed on 08/19/2025, it was determined that the facility failed to maintain in appropriate safety state medical equipment. Findings include: 1. During the Emergency Services room tour performed on 08/19/2025 till 08/20/2025 from 8:00AM to 12:00PM accompanied by the emergency room manager (employee #7) the following was observed: a. The handrails of three (3) beds were corroded with rust. b. There were 7 wheelchairs in use of which 4 were in a state of disrepair with the handrails corroded by rust and the vinyl broken or worn from use. c. The pediatric car defibrillator had no maintenance or inspection stamp. d. The maintenance of the isolation negative pressure room was due on 01/16/2025. 2. During the pediatric care unit tour performed on 08/19/2025 at 1:30PM accompanied by the infection control coordinator (employee #8) it was observed that the pediatric car defibrillator had the maintenance due on 12/2024. 47632 3. During observations made on 08/19/2025 from 8:26 AM to 3:00 PM in the recovery area, the following were found: a. Stained acoustic cubicles were observed. b. Hyperthermia was observed in the briefcase: - Three IV start kits expired on 12/31/2024 and 02/01/2025. - Five 5-milliliter (ml) syringes expired on 08/04/2025. c. Patient bathroom with stained acoustic cubicles. d. Nursing station with stained earplugs. e. Cardiac monitors without up-to-date preventive maintenance were observed in cubicles. 4. During observations made on 08/19/2025 from 9:00 AM to 3:00 PM in the holding area, the following were found: a. 29 purple EDTA tubes expired on 06/30/2025 and 07/30/2025. 5. During observations made on 08/19/2025 from 10:00 AM to 3:00 PM in the storage room, the following were found: a. Stained acoustic devices were observed. b. Supply boxes placed on the floor. 6. During observations made on 08/19/2025 from 10:00 AM to 3:00 PM in the infusion center, the following were found: a. A vital signs monitor without updated preventive maintenance (expired 10/2024) was observed. 7. During observations made on 08/19/2025 from 10:00 AM to 3:00 PM in the formula room, the following were found: a. Stained acoustics were observed. b. Eye saline solution of 946 ml expired 01/2024 was observed. 8. During observations made on 08/19/2025 from 11:00 AM to 3:00 PM in operating rooms A, B, C, and D, the following were found: a. Four out of four medication carts were observed in the rooms, open with high-risk medications in them. On 08/14/2025 at 11:24 AM, the head nurse anesthetist (employee #21) was interviewed and reported that they did not have the key to open and close the medication carts. Pharmacy staff were notified of the situation and took action. Three of the four medication carts were repaired at that time. b. Four out of four cardiac monitors on the anesthesia cart were observed to be without current preventive maintenance. c. A size 5 laryngeal mask airway with an expiration date of 06/30/2025 was observed in room C. d. A table with dark stains was observed in room C. e. A chipped oxygen tank with missing paint and dark stains was observed in room C. f. Four out of four anesthesia medication carts were observed with panels showing dark spots. g. The Washer Disinfector was observed in the sterilization room with preventive maintenance performed on 03/2023. i. The autoclave in the sterilization room was observed to have undergone preventive maintenance on 07/2024. h. observed in room C, wall coming loose.”

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 51637 Based on observation tours performed on 08/19/2025, it was determined that the facility failed to maintain appropriate monitoring of lighting, temperature and negative pressure in the required areas. (Cross Reference TAG A0750) Findings include: 1. During the facility tour for infection control purposes performed on 08/19/2025 from 1:00PM till 3:00PM accompanied by the infection control coordinator (employee #8) the following was observed: a. The room where the wheelchairs used in the emergency room are kept had no lighting, no temperature or humidity control and a wet floor. b. The soiled linen room located on the outside of the facility, near the garbage area, had no ventilation, exhaust fan or negative pressure. c. The soiled linen room located on the intensive care area was without lock and had no exhaust fan nor negative pressure. d. The soiled linen room located on the medicine care area was without lock and had no exhaust fan nor negative pressure. e. The measure clock of the isolation negative pressure room (213) on medicine care area was off and the maintenance was due on 01/29/2025. f. The negative pressure rooms (7 and #8) in the intensive care areas had no measure clock outside, neither maintenance or function evidence and the doors were open. g. The negative pressure room in the pediatric care area had no measure clock outside, neither the maintenance or function evidence.”

“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: 51637 Based on observation, records, documents reviewed, and interview performed on 08/19/2025 till 08/20/2025, it was determined that the facility failed to have a policy and procedure to follow for the insolation room requirements. (Cross Reference Tag A0454) Findings include: During the review of the infection control policies and procedures manual performed on 08/19/2025 at 2:10PM accompanied by the infection control coordinator (employee #8), no policy was found for the process to be followed with patients in isolation rooms.”

“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 tour and documents reviewed performed on 08/19/2025 till 08/20/2025 ,it was determined that the facility failed to prevent and maintain the staff and patients free of infection risk. (Cross Reference Tag A0726) Findings include: 1. During the facility tour for infection control purposes performed on 08/19/2025 from 1:00PM till 3:00PM accompanied by the infection control coordinator (employee #8) the following was observed: a. The soiled linen room located on the outside of the facility, near the garbage area, had no ventilation, exhaust fans or negative pressure. b. The soiled linen room located on the intensive care area was without lock and had no exhaust fan nor negative pressure. c. The soiled linen room located on the medicine care area was without lock and had no exhaust fan nor negative pressure. d. The measure clock of the isolation negative pressure room (213) on medicine care area was off and the maintenance was due on 01/29/2025. e. The negative pressure rooms (7 and #8) in the intensive care areas had no measure clock outside, neither maintenance or function evidence and the doors were open. f. The negative pressure room in the pediatric care area had no measure clock outside, neither maintenance nor function evidence. g. The hand washing sink in the biohazard can trash area had no soap or paper dispenser or alcohol base hand sanitizer. 2. During the review of the hospital employee roster and determination of the face seal percentage for N95 mask use performed on 08/20/2025 at 11:12AM it was determined that the seal percentage is 43% for the total facility. 47632 3. R.R #13 is a 53-year-old woman admitted on 08/18/2025 for an excisional biopsy. At 10:08 AM, during the procedure, it was observed that the circulating nurse did not wash her hands or use hand sanitizer on two occasions before putting on gloves. At 10:13 AM, the nurse anesthetist failed to wash her hands or use hand sanitizer on four occasions before putting on gloves. At 10:15 AM, the nurse anesthetist placed the Surgical Hole Towel Surgery on the patient’s IV stand. 4. During observations made in rooms A, B, C, and D on 08/19/2025 at 9:01 AM, the following was found: a. In room C, 0.5% Bupivacaine 150 milligrams (mg)/30 ml single dose was observed without being discarded. b. In Room C, 1% Xylocaine 200 mg/20 ml was observed without a date or signature from the staff who opened it. 51629 5. Room # 130 - one height adjustable over bed dining table with rust on the base and two beds with rust on its base and side railings. 6. RR # 37 is a 90 -year-old female who was admitted on 08/18/2025 with a diagnosis of NStemi. The patient was on a bed with rust, including its base and side railings. Also, she was receiving intravenous fluids located on an IV stand with rust on its base. 7. RR # 54 is a 51 -year-old female who was admitted on 08/17/2025 with a diagnosis of Cellulitis of Left Lower Leg. The patient was on a bed with rust, including its base and side railings. Also, she was receiving intravenous fluids located on an IV stand with rust on its base. 8. Intensive care unit - Dirty linen cart with a packed equipment on the top of it and near the staff lockers. 9. Medicine ward - Wooden shelf overfilled with intravenous fluids, covered with Formica, which was peeling in several places. 10. Rooms # 200 and # 216 - Overfilled sharp containers on the wall. There were patients in both rooms: a. RR # 36 is an 82 - year-old-male who was admitted on 08/17/2025 with a diagnosis of Hypertensive Crisis. b. RR # 1 is a 57 - year-old-male who was admitted with a diagnosis of Altered Mental Status. The facility failed to provide a clean and sanitary environment to avoid sources and transmission of infection and safety.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 47632 Based on observations made in the procedures manual dated 08/20/2025, it was determined that the facility failed to ensure that the manual contained policies designed to guarantee the achievement and maintenance of high standards of medical practice and patient care. Findings include: During the review of the operating room standards and procedures manual with the associate director of the operating room (employee #17) and the head registered nurse ( employee #16) on 08/20/2025 at 8:50 AM, a lack of standards and structure for infection prevention and control was observed.”

“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 08/19/2025, it was determined that the facility failed to ensure that cardiac monitor equipment was inspected, tested, and maintained. Findings include: During observations made in the operating rooms on 08/19/2025 and 08/20/2025 from 9:00 AM to 3:00 PM, it was found that in rooms A, B, C, and D, the cardiac monitors on the anesthesia cart had expired preventive maintenance since 01/2022.”

“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 policies and procedures with the head nurse anesthetist ( Employee #21) on 08/20/2025, it was determined that the facility failed to ensure that the standards and procedures manual included infection control prevention measures. Findings include: During observations made at 1:20 PM with the head anesthesia nurse (employee# 21) and the anesthesiologist (employee# 18) regarding the standards and procedures manual, it was found that there was a lack of infection control policies and structure.”

“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 08/21/2025 at 1:00 PM through 2:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include revisions to their emergency preparedness plans, Emerging Infectious diseases are a potential threat which can impact the operations and continuity of care within a healthcare setting. Findings include: During the review of the facilities Emergency Preparedness Program with the facility’s Operation Director (employee #6) and Safety Officer (employee #5), it was noted that the facility failed to include emerging infectious diseases ( Influenza, Ebola, Zika, etc.) in the Emergency Plan.”

“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 08/21/2025 at 1:00 PM through 3:30 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 Operation Director (employee #6) and Safety Officer (employee #5), it was noted that the EP failed to have written procedures to track location of patients and staff if relocated during an emergency.”

“Policies for Evac. and Primary/Alt. Comm. CFR(s): §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(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:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], 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 RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; 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 08/21/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide policies and procedures of safe evacuation from the facility. Findings include: During the review of the facilities Emergency Preparedness Program with the Operations Director ( employee #6), Safety Officer (employee #5), it was noted that the facility failed include staff responsibilities, evacuation locations, and primary and alternate means of communication with external sources of assistance.”

“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 08/21/2025 at 1:00 PM through 3:30 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 Operations Director (employee #6) and Safety Officer (employee #5), 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.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 47384 Based on an Emergency Preparedness Program (EPP) survey performed on 08/21/2025 at 1:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed perform exercises to test the emergency plan annually. Findings include: Facility did not conduct exercises to test emergency plan as required on 482.15(d)(2).”

“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 08/21/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to implement a emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code . Findings include: During the review of the facilities Emergency Preparedness Program with the facility Operation Director (employee #6) and Safety Officer (employee #5), it was noted that the EP failed to state maintanance and regular tessting as required.”

“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 #5), Engineering Manager (employee #4) and operational manager (employee #6), it was determined that the facility failed to maintain the width of aisles or corridors serving as exit access at least 4 feet and maintained to provide the convenient removal of non-ambulatory patients 19.2.3.4, 19.2.3.5. Findings include: Approximately at 8:30 AM on 08/19/2025 an unattended stretcher, two carts with clean linen and a sphygmomanometer were observed on both sides of corridor in the medicine department area reducing exit access to less than three-foot six inches wide. Approximately at 9:45 AM on 08/19/2025 an unattended stretchers and medical equipment were observed on both sides of corridor between rooms A and B in the Surgery Department reducing exit access to less than three-foot six inches wide. Approximately at 2:00 PM on 08/20/2025 plastic containers were observed in corridor obstructing exit door. The finding was verified by the Safety Officer, Head of Engineering and Operational Director at the time of the observation”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 47384 The facility failed to provide exit doors in the means of egress readily accessible and free of all obstructions or impediments to full instant use in the case of fire or other emergencies in accordance with the requirements of NFPA 101, 2012 Edition, Section 19.2.2.2.5.1, 19.2.2.2.5.2 and 19.2.2.2.6. Findings include: 1. Ulcer Unit back exit door (leads to the parking), revealed thumb turn locks on the egress side. The thumb turn lock and fastening device on the door could restrict emergency use of the exit. 2. Broken push bar on exit door on Surgery Department next to Operating Room (OR) B. 3. Push bar was observed rusted and dificult to open in arae identified as Zone E exit. 4. Push bar on emergency exit door was observed with broken components on the MRI area. 5. Push bar on emergency exit door was observed with broken components on the Physical Therapy area. 6. Emergency exit door was dificult to open on the Physical Therapy area. 7. Pharmacy back exit door (leads to the parking), revealed thumb turn locks on the egress side. The thumb turn lock and fastening device on the door could restrict emergency use of the exit. 8. Push bar on emergency exit door was observed with broken components next to the Chapel. 9. Push bar on emergency exit door was observed with broken components on the west side exit area.”

“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 #5), Engineering Manager (employee #4) and Operational Manager (employee #6), 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 08/19/25 approximately at 9:30 AM it was observed that the emergency shut-off valves on Surgery Department were blocked by medical equipmnet. 3. On 08/19/25 approximately at 9:45 AM it was observed that the emergency shut-off valves on Surgery Department Room C were blocked by Sterile medical equipmnet. 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 interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #5), Engineering Manager (employee #4) and Operational Manager (employee #6), 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 back exit of Ulcer Center . 3. No battery backup emergency light above the generator. 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 observations and interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #5), Engineering Manager (employee #4) and Operational Manager (employee #6),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 08/19/2025 at approximately 9:30 AM, on the Emergency Department it was noticed that no exit sign were provided in the area stating means of egress from the CPR area. 2. Observation and interview on 08/19/2025 at approximately 9:35 AM, on the Emergency Department it was noticed that no exit sign were provided in the area stating means of egress from the pediatric area. 3. Observation and interview on 08/19/2025 at approximately 11:10 AM, on the Pediatric Unit, sign should be relocated in order to be apparent from all locations of the room, the chevron must be covered to avoid confusion. 4. Observation and interview on 08/20/2025 at approximately 10:45 AM, on the Physical Therapy area, no exit signs were observed (2) on doors on opposite sides. 5. Observation and interview on 08/20/2025 at approximately 10:45 AM, on the Ulcer Treatment area, no exit sign was found detailing egress to through the front of unit. 6. Observation and interview on 08/20/2025 at approximately 1:10 PM, on the Water Heating Machanical Room, no exit sign was observed on either of the exits. 7. Observation and interview on 08/20/2025 at approximately 1:50 PM, on the Chiller and A/C Machanical Room, no exit sign was observed on either of the exits. 8. Observation and interview on 08/20/2025 at approximately 1:50 PM, on the Laboratory Department, no exit sign was observed on either of the exits (2). 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. Water Pump Mechanical room ABHR were found blocking medical gases shutoff valves in the following areas: 1. Recovery area on Surgery Department 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 detection devices in accordance with NFPA72 and 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5. Findings include: 1. No smoke detectors were observed any of the 4 Surgery Rooms. 2. No smoke detectors were observed on rooms 1 and 2 on Intensive Care Unit. 3. Smoke detector on IT Server Room was to close to air conditioning vent, this can cause the smoke detector to not function correctly The finding was verified by the Safety Officer and Engineering Director 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 08/19/2025 through 08/21/2025 revealed that there are no visual (strobe) or audible signals in public area bathrooms (main lobby and Emergency Room waiting area, Ulcer Unit waiting area). 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 and interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #5), Engineering Manager (employee #4) and Operational Manager (employee #6), 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 08/19/2025 approximately at 2:10 PM it was noticed that fire extinguisher was blocked by a crash cart on the Delivery Room area. 2. On 08/20/2025 approximately at 10:30 AM a fire extinguisher was observed blocked by trashcans in the injection area on the Ulcer unit. 3. On 08/20/2025 approximately at 1:30 PM a fire extinguisher was observed obstructed by electrical panel PP-8-CK2 on the Water Heater Mechanical Room 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 and interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #5), Engineering Manager (employee #4) and Operational Manager (employee #6),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: 1.During the tour for life safety from fire on 08/19/2024 through 08/21/2024 from 8:00 AM through 4:00 PM, patient’s sleeping room doors were tested it was found that patient’s sleeping rooms #134, #200, #201, #203, #205, #208, #209, #212,#220, #225, #233, #235, #237, #238, #240 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. 2. Smoke Barrier door on second floor (south corridor), Mediicne Department was observed to not latch. 3. Smoke Barrier door near MRI area does not latch. 4. Room doors #2, #4, #5, #7 and #8 on Intensive Care Unit do not latch. 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 08/19/2025 through 08/21/2025 from 8:00 AM to 4:00 PM, it was determined that the facility failed to ensure fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (2010 NFPA 80). Findings include: 1. No written records of inspection and testing are maintained and are available for review at the moment of the survey. 2. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, were not routinely inspected as part of the facility maintenance program.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for life safety from fire of the Hospital with the facility’s Safety Officer (Employee #5), Engineering Manager (employee #4) and operational manager (employee #6), it was determined that the facility failed to maintain areas free of portable space heating devices. 18.7.8, 19.7.8 Findings include: Portable heater was obseverd on Doctors office on the Emergency Room (ER).”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations and document review made during the survey for life safety from fire on 08/19/2025 through 08/21/2025 from 8:00 AM to 4:00 PM, it was determined that the facility failed to ensure the gas and vacuum systems are in optimal conditionsas part of a maintenance program and include the required elements. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) Findings include: 1. Facility provided Annual report “ Medical Gases Annual Verification” report performed by external provider on December 2024. This report indicates that: a. Medical Air compressor is not acceptable for medical porpose and does not comply with NFPA 99. b. The Medical Vacuum System does not comply with NFPA 99 At the moment of the survey the facility has not corrected issues identified on the inspection performed. The finding was verified by the Safety Officer, Engineering Manager and Operational Manager”

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

“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 08/19/2025 through 08/21/2025 from 8:00 AM to 4:00 PM, 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) 6 receptacles on oparation room C in the surgery department 2. One (1) 4 receptacles on oparation room C in the surgery department 3. One (1) on doctors office in the emergency room 4. One (1) on telemetry counter 5. One (1) on Laboratory Department Urinalisis Counter 6. One (1) on Pharmacy Department station”

“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 08/19/2025 through 08/21/2025 from 8:00 AM to 4:00 PM, it was determined that the facility failed to observe precautionary measures to ensure safety on the cylinder storage as requested on 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) Findings include: On 08/20/2025 approximately at 2:30 PM at the cylinder yard the following was observed: 1. One (1) Type H oxygen tank was observed not fastened with chain. 2. One (1) Type E helium tank was observed directly on the floor with no stand to hold. 3. Twenty two (22) Type E mixed tanks were observed un fastened on rack. 4. Three (3) 40cu/ft helium tanks were observed un fastened. 5. Outside walls of storage area was not properly identified by signs. 6. No signage identified empty or full tanks.”

“Hyperbaric Facilities CFR(s): NFPA 101 Hyperbaric Facilities All occupancies containing hyperbaric facilities comply with construction, equipment, administration, and maintenance requirements of NFPA 99. Chapter 14 (NFPA 99) 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 #5), Engineering Manager (employee #4) and Operational Manager (employee #6), failed to maintain occupancies containing hyperbaric facilities comply with construction, equipment, administration, and maintenance requirements of NFPA 99. Findings include: 1. On 08/20/25 approximately at 11:45 AM it was observed that the electrical cables tomachine integrity was compromised due to electrical black cable covering cable to plug. 2. On 08/20/25 approximately at 11:45 AM it was observed that no quick release was present on oxygen hose connected to chamber as required on NFPA 99. 3. On 08/20/25 approximately at 11:45 AM it was observed that emergency shutoff valves were located in the back wall and were difficult to reach.”