Professional Hospital Guaynabo Inc.

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. 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); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 17959 Based on review of the Quality Assessment and Performance Improvement (QAPI) Program and interview with the Quality Coordinator (employee #10) performed on 09/10/2025 and 09/11/2025 at 9:00 AM till 2:00 PM, it was determine that the facility failed to develop, implement and maintain an effective, ongoing, data-driven QAPI program that include all departments and contract services to participate in the annual Quality Program which make this Condition of Participation: Quality Assessment and Performance Improvement Program not met. (Cross refer: Tag A0308) Findings include: On an interview with the Quality Officer (employee #10) performed on 09/11/2025 at 10:50 AM she states that the Facility has a Quality Annual Plan for 2025. She presents a calendar of meetings, and a program for delivering indicators by departments. However, while reviewing the indicators per department the following was identified: 1. The Quality officer stated that the contracted services of Anesthesia Services, Dialysis Service, Hato Rey Pathology and Perfect Cleaning did not present Quality indicators, improvement project, adverse event and they do not participate in meetings of quality program. 2. The Quality officer stated that the Hospital X Ray department and Diet department did not present quality indicators, improvement project, adverse event and they do not participate in meetings of quality program. 3. The Quality officer stated that the Diet department has a registry of humidity and temperatures, they have a record of expired food, but it is not sent to the quality officer. The quality officer stated that the diet department officer did not present quality indicators, improvement project, adverse events and they did not participate in meetings of the quality program. She stated regularly if there are any complaints from patients, she meets with quality and nursing director only. Quality keeps a record of patient satisfaction, and they regularly complain about diet related to food temperatures.”

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 47384 Based on observations and interviews made during the Recertification survey of the Hospital with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to maintain the generator or other alternate power source and associated equipment to supply service within 10 seconds, which resulted on an Immediate Jeopardy. (Cross Refer Tag A0702) Findings include: On 9/9/2025 at 10:00 am a Puerto Rico Power Authoirty (LUMA) power outage occurs, alternative power (generator) was recovered 37 seconds after the event. During the 37 seconds that the facility was without power (neither from the power grid nor the generator) employees were observed holding cellular phone light to during procedures being performed in the surgical suites #1 and #6. Also complete hallways were observed with no emergency light functioning. Approximately at 1:41 PM the facility’s Project Manager request that the surveyor visit the the generators and the transfer switch area. The external company that provides service to the Hospital had completed the reprogramming process for both the three generators and the transfer switch. A test was conducted in the presence of the surveyor during which the facility was disconnected from the power grid and the generators started up in 8 seconds. Facility provided plan of correction at 2:52 PM A. TAG K918 Electrical Systems - Essential Electric System Maintenance and Testing B. Plan for correcting the deficiency 1) The Physical Plant Supervisor immediately contacted the power generator maintenance contractor (Today Smart Energy). 2) Technician updated the system programming and conducted tests in presence of surveyor LSC Lead Surveyor (See. Attachment 1). 3) During testing, generator start time was measured at three seconds. 4) During testing, the transfer load time was measured at eight (8) seconds. 5) The system was determined to be compliant with NFPA 110 standard. 6) The emergency light in the OR was replaced and observed to function properly. C. Plan for improving the process 1) The hospital has contracted the services of an independent firm to assist hospital personnel in conducting tests for maintaining compliance. 2) The system was determined to be compliant with NFPA 110 standard. E. Procedure for implementation 1) The physical plant has determined to update the testing schedule. 2) The hospital has contracted a firm to monitor compliance with transfer time. F. Tracking Procedure The hospital has contracted the services of an independent firm to assist hospital personnel in conducting tests for maintaining compliance. The maintenance schedule will include verification of transfer time metrics for assessment. G. Responsible Individuals 1) Department Supervisor 2) Physical Plant Director 3) Hosp. Administrator Surveyor accepted plan at 2:55PM.”

“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 personnel credential files (CF) and State Law License regulations requirements, seventeen radiology credential file (RCF), it was determined that the facility failed to updated personnel credential files related to professional staff comply with the Cardiopulmonary Resuscitation (CPR) and Hepatitis , Influenza Vaccine, Health certificate, an updated annual evaluation, criminal record certificate and appointment as department/services director . This deficient practice was identified in 49 out of 49 personnel credential files reviewed. Findings include: 1.RCF # 3, #7 and # 12 had an expired (CPR) certificate. 2. RCF # 3 and # 12 had an expired Health certificate. 3. Eleven out of eleven radiology department credential files reviewed with the radiology department supervisor, including radiology department supervisor, do not have evidence of an updated Annual Evaluation. 4. RCF # 15 and # 16 had an expired Criminal Record certificate. 5. RCF # 17 was recruited to work at the radiology department on 07/22/2024 and did not have evidence of the Criminal Record certificate. 6. RCF # 13 radiology department supervisor, was recruited to work at the radiology department on 02/19/2023 and did not have and an appointment as radiology department supervisor. 51637 7. During the credential files review of diet and pharmacy staff conducted from 09/09/2025 to 09/10/2025 from 1:00pm to 2:00pm, the following was found: a) 5 of the 7 ( Credential File #1, #2, #3, #4 & #6) employees working in the pharmacy have no evidence of hepatitis B vaccine administration or positive titers. b) 7 of the 7 employees ( C.F. #1, #2, #3, #4, #5, #6 & #7) working in the pharmacy have no evidence of annual evaluations or competencies. c) 1 of the 7 (C.F. #5) employees of the pharmacy has an expired health certificate since 05/30/2025. d) The clinical dietitian’s record (employee #1) (C.F. #1) has no evidence of vaccination or refusal of influenza, the health certificate on the file was expired since 06/10/2020, and there was no evidence of annual evaluation. e) The kitchen supervisor’s file (employee #2)(C.F. #2) had no evidence of influenza vaccination or rejection, and no evidence of annual evaluation was found. f) The kitchen manager’s file (C.F. #3) did not have evidence of vaccination or refusal of influenza vaccine, vaccination or positive hepatitis B titers, the health certificate was expired since 08/05/2025 and no evidence of annual evaluation was found. 17959 8. During the credential files review of Medical Record staff conducted on 09/09/2025 from 10:10 AM to 11:30 AM, the following was found: a) Employee #5 did not have no evidence of Hepatitis B vaccine administration or positive titers. b) Employee #1 and #5 did not have no evidence of Influenza vaccine administration. c) Employees #1, #2, #5, #4 and #5 have no evidence of Annual evaluations or competencies. d) Employees #1 has an expired health certificate since 01/23/2024 and employee #5 has expired health certificate since 09/09/2023. e) Employees #1 (04/13/2023 to 2024), #2 (11/29/2022 to 2023) and #5 (04/05/2023 to 2024) did not have evidence of actually Criminal record. 51782 9. During the credential files review of emergency room department nurses staff performed on 09/10/2025 to 09/11/2025 from 2:30 PM to 3:30 PM, the following was found: a) One out of eight credential files failed to show updated evidence of in person Cardiopulmonary Resuscitation (CPR) accredited by the American Heart Association, the evidence provided was online CPR (N.C.F #7). b) Six out of eight credential files failed to show updated evidence of the annual evaluation (N.C.F. #1, #2, #4, #5, #6, #7). 10. During the credential files review of Social Work staff performed on 09/10/2025 to 09/11/2025 from 2:30 PM to 3:30 PM, the following was found: a) One out of one credential file failed to show updated evidence of the annual evaluation (S.W.C.F. #1). 51829 11. During the credential review on 12 of 12 employees on 10/09/2025 and 11/09/2025, it was identified and confirmed in an interview on 11/09/2025 at 9:00 a.m. with the Director of Nursing (Employee #9) that annual staff evaluations are not conducted, and it was identified that they do not have the Law 300 “Back Ground Check” certificate. 12. During the review, expired or missing credentials were identified: a. During the review, it was identified that Employee #7 has no evidence of being licensed. b. During the review, it was identified that Employees #3 and #5 had their CPR expired on 10/09/2025 and have no evidence of having taken it. c. During the review, it was identified that employee #3 had a flu vaccination dated 09/09/2023 and #5 had a vaccination dated 10/18/2022, and they did not have any evidence of re-injection. d. During the review, it was identified that employee #2, dated 10/24/2024, employee #3, dated 01/19/2023, employee #6, dated 07/18/2024, employee #10, dated 08/01/2024, and employee #11, dated 03/21/2025, did not have any updated criminal records. e. During the review, it was identified that employee #11 did not have any evidence of the COVID vaccine.”

“MEDICAL STAFF CFR(s): 482.12(a) The governing body must: This Standard is not met as evidenced by: 20423 Based on twenty-two physician credential files reviewed, it was determined that the governing body failed to ensure that the medical staff requirements as physician privileges are met for 11 out of 22 physician credential files (PCF) reviewed. P.C.F #6, 7, 8, 10, 11, 12, 14, 15, 16, 17 and #18. Findings include: During the review of twenty-two physician credential File (P.C.F) with the administrator employee #4, it was found the following: The Medical staff bylaws, rule and regulator was reviewed on 09/10/2025 at 10:00 am provided evidence that was reviewed and approved by the Board Director on 04/02/2024. It establish in page 9 Section D Term of Appointment establish Medical & AHP staff appointment and reappointment shall be for no more than two (2) years. 1. Eleven out of twenty -two physician credential files provide evidence that the physician privileges were expired as follows: a. P.C.F #6 provide evidence that the privileges expired on 06/30/2025. b. P.C.F #7 provide evidence that the privileges expired on 03/30/2025. c. P.C.F #8 provides evidence that the privileges expired on 09/01/2025. d. P.C.F #10 provide evidence that the privileges expired on 06/30/2025. e. P.C.F #11 provide evidence that the privileges expired on 06/30/2025. f. P.C.F #12 provide evidence that the privileges expired on 06/30/2025. g. P.C.F #14 provide evidence that the privileges expired on 06/30/2025. h. P.C.F #15 provide evidence that the privileges expired on 01/29/2025. i. P.C.F #16 provide evidence that the privileges expired on 01/29/2025. j. P.C.F #17 no evidence was found of the privileges. k. P.C.F #18 provides evidence that the privileges expired on 06/30/2025. 2. No evidence was found that physician privileges were in the process of reappointment by the facility Governing body.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 51629 Based on interviews with the Discharge Planning coordinator (employee # 20), Registered Nurse of the Discharge Planning service (employee # 21), documents reviewed, and five records reviewed (RR) performed on 09/11/2025 at 8:30 AM, it was determined that the facility failed to inform each patient of their rights, in advance of furnishing or discontinuing patient care. This deficient practice was identified in 5 out of 5 closed records reviewed (RR # 65, # 77, # 78, # 79 and # 80) and 2 out of 2 open records reviewed (RR # 22 and RR # 56). Findings include: During interview with Social Worker (employee # 20) on 09/11/2025 at 11:00 AM, she stated that in each intervention the discharge program staff guides the patients about their rights, but they do not provide the important Medicare message at least 2 days before discharge. 1.RR # 65 is an 87-year-old female Medicare beneficiary who was admitted on 08/20/2025 with a diagnosis of Spontaneous Pneumothorax and Pneumonia. The patient was discharged home on 08/28/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to discharge. 2.RR #77 is an 80-year-old female Medicare beneficiary who was admitted on 08/10/2025 with a diagnosis of Atherosclerosis of lower extremities with left firs toe infected ulcer. The patient was discharged home on 08/18/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to discharge. 3.RR #78 is a 78-year-old female Medicare beneficiary who was admitted on 07/28/2025 with a diagnosis of Bilateral leg necrotic stasis ulcers. The patient was discharged home on 08/10/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to discharge. 4.RR #79 is a 93-year-old female Medicare beneficiary who was admitted on 07/31/2025 with a diagnosis of Pneumonia. The patient was discharged home on 08/15/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to discharge. 5.RR #80 is a 80-year-old female Medicare beneficiary who was admitted on 07/31/2025 with a diagnosis of Sepsis due to Pyelonephritis. The patient was discharged home on 08/11/2025. The clinical record did not evidence that a copy of Medicare Important Message was provided 2 days prior to discharge. The facility failed to inform each patient of their rights at least 2 days prior to discharge. 6. RR # 22 is a 95-year-old female who was admitted on 9/1/2025 with a diagnosis of Bed Confinement Status. On 9/2/2025 at 8:00 AM, a surgery consent form was documented, signed and dated by the surgeon and patient representative. The document states that the patient was going to undergo the following surgery: Aortoiliac arteriogram on the left leg with possible revascularization. The clinical record includes an anesthesia permission form called: “Formulario de Información sobre Servicio de Anestesia y Formulario de Consentimiento”. It is signed by the patient’s representative but not dated, nor signed and dated by the anesthesiologist. 7.RR # 56 is a 96-year-old male who was admitted on 09/04/2025 with a diagnosis of Digital Subtraction Angiography (DSA) possible Autotaxin (ATX). On 9/9/2025 at 10:20 AM, a surgery consent form was documented, signed and dated by the patient representative but not signed nor dated by the surgeon. It states that the patient was going to undergo the following surgery: Left leg revascularization. 8. The facility failed to inform each patient of their rights, in advance of furnishing patient care.”

“PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee.] The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 51629 Based on interviews with the Admission Department Supervisor (employee # 31) and document review performed on 09/9/2025 at 9:00 AM, it was determine that the facility failed to establish a process for prompt resolution of patient grievances and inform each patient whom to contact to file a grievance. Findings include: The policy “Derechos del Paciente”, Patients’ Rights as part of the admission documents, was discussed and reviewed with the Admission Department Supervisor (employee # 31) on 09/9/2025 at 9:00 AM. The facility document provides an outdated address, phone numbers, and email address for filing federal and state complaints. 1.The facility failed to establish a process for prompt resolution of patient grievances and inform each patient whom to contact to file a grievance. During survey, The facility staff was provided with updated information and the deficiency was corrected on site.”

“PATIENT RIGHTS: GRIEVANCE PROCEDURES CFR(s): 482.13(a)(2)(i) [At a minimum:] The hospital must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital. This Standard is not met as evidenced by: 51629 Based on interviews with the Emergency Room Admission Clerks Supervisor (employee # 32) and records reviewed performed on 09/10/2025 at 9:30 AM, it was identified that the facility failed to implement and maintain a clearly explained procedure for the submission of a patient’s or representative to submit written or verbal grievances. This deficient practice was identified in 2 out of 2 open and closed records reviewed (RR # 23 and RR # 65). Findings include: During interview with the Emergency Room Admission Clerks Supervisor (employee # 32) and record review performed on 09/10/2025 at 9:30 AM, she stated that during the admission procedure, the documents to be provided to patient and relative include all their rights, including the procedure for written or verbal grievances. 1.RR # 65 is a 87-year-old female Medicare beneficiary who was admitted on 08/20/2025 with a diagnosis of Spontaneous Pneumothorax and Pneumonia. The patient was discharged home on 08/28/2025. The clinical record did not evidence that a copy of the procedure for written or verbal grievances was provided. 2. RR # 23 is a 69-year-old male Medicare beneficiary who was admitted on 08/26/2025 with a diagnosis of Right foot ulcer. During record review performed on 9/10/2025, the patient was still hospitalized but the clinical record did not evidence that a copy of the procedure for written or verbal grievances was provided. The facility failed to maintain and demonstrate evidence that, during the admission process, the procedure about how to submit written or verbal grievances is clearly explained to patients or relatives.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 51629 Based on interviews with the Intensive Care Unit Supervisor (employee # 11), document review, and record review performed on 09/10/2025 at 1:30 PM, it was determine that the facility failed to protect the rights of the patient or relative to participate in the development and implementation of his or her plan of care. This deficient practice was identified in 1 out of 1 case reviewed (RR # 22). Findings include: The facilitys’ policy named: Protocolo y Política de Restricción de Pacientes- Policy and Procedure of Patient Restriction, (01/2025 effective date) was reviewed on 09/11/2025 at 11:00 AM. The facility policy states that the patient and family should be educated about restraint and provided with educational materials. This action should be documented in the clinical record. A record was reviewed with Intensive Care Unit Supervisor (employee # 11) on 09/10/2025 at 1:30 PM. 1. RR # 22 is a 95-year-old female who was admitted on 9/1/2025 with a diagnosis of Bed Confinement Status. On 9/10/2025 at 10:32 AM, the physician prescribed a telephone order to restrain the upper extremities. No evidence was provided to indicate that the patient’s representative was notified, educated, and participated in the implementation of the care plan related to restraint. 3. The facility failed to protect the rights of the patient or relative to participate in the development and implementation of his or her plan of care.”

“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: 51629 Based on interviews with the hospital Admission Department Supervisor (employee # 31), records reviewed performed on 09/09/2025 at 9:00 AM, Emergency Room Admission Clerks Supervisor (employee # 32) and records reviewed performed on 09/10/2025 at 9:30 AM, it was identified that the facility failed to implement and maintain a procedure for the submission of advance directives and to have hospital staff and practitioners who provide care in the hospital to comply with these directives. This deficient practice was identified in 8 out of 8 open and closed records reviewed (RR . #22, 23, 25, 30, 56, 65, 66 and 67). Findings include: During an interview with the Emergency Room Admission Clerks Supervisor (employee # 32) and record review performed on 09/10/2025 at 9:30 AM, she stated that during the admission procedure, the documents to be provided to patient and relative contain all their rights, including the procedure for submission of advanced directives. 1. RR # 65 is an 87-year-old female Medicare beneficiary who was admitted on 08/20/2025 with a diagnosis of Spontaneous Pneumothorax and Pneumonia. The patient was discharged home on 08/28/2025. The clinical record did not evidence that a copy of the procedure for advanced directives submission was provided. 2. RR # 23 is a 69-year-old male Medicare beneficiary who was admitted on 08/26/2025 with a diagnosis of Right foot ulcer. During record review performed on 9/10/2025, the patient was still hospitalized but the clinical record did not evidence that a copy of the procedure for advanced directives submission was provided. During an interview with the Intensive Care Unit Supervisor (employee # 11) and records reviewed performed on 09/10/2025 at 11:00 AM, she stated that according to current hospital procedure, the Do Not Resuscitate/ Do Not Intubate- DNR/DNI consent form acts as a physician order. The policy named: “Política y Protocolo para Directrices Médicas Anticipadas / DNR & DNI Policy and Protocol for Anticipate Medical Directive/DNR & DNI (07/01/2024 revision) was reviewed on 09/11/2025 at 11:30 AM. The facility policy states that the physician will discuss matters related to advance directives and will sign the form as evidence that he/she instruct the patients, but it does not require a physician order. 3 .RR # 66 is an 86-year-old female who was admitted on 09/07/2025 with a diagnosis of Stenosis Right Carotid. A consent form for DNR/DNI was signed and dated 9/8/2025. The clinical record did not evidence a physician order for DNR/DNI. 4. RR # 30 is an 89-year-old female who was admitted on 09/09/2025 with a diagnosis of Severe Sepsis with Septic Shock. A consent form for DNR/DNI was signed and dated 9/9/2025. The clinical record did not evidence a physician order for DNR/DNI. 5. RR # 56 is an 96-year-old male who was admitted on 09/04/2025 with a diagnosis of DSA possible ATX. A consent form for DNR/DNI was signed and dated 9/4/2025. The clinical record did not evidence a physician order for DNR/DNI. 6. RR # 67 is an 80-year-old female who was admitted on 09/03/2025 with a diagnosis of Urinary Tract Infection. A consent form for DNR/DNI was signed and dated 9/5/2025. The clinical record did not evidence a physician order for DNR/DNI. 7. RR # 22 is a 95-year-old female who was admitted on 09/01/2025 with a diagnosis of Bed Confinement Status. A consent form for DNR/DNI was signed and dated 9/7/2025. The clinical record did not evidence a physician order for DNR/DNI. During an interview with a Third floor Registered Nurse (employee # 22) and record reviewed performed on 09/11/2025 at 10:00 AM, she stated that for patients who refuse blood transfusions and according to current hospital procedure, there is a copy of the advance directive document provided by the patient that it is kept in the clinical record. The latest form acts as a physician order. 8. RR # 25 is a 76-year-old female who was admitted on 09/07/2025 with a diagnosis of Congestive Heart Failure. The advanced directives section on the admission documents was not documented nor signed. An advance directive form refusing blood transfusions and life-prolonging measures was signed and dated 7/8/2017. The clinical record did not evidence a consent form for DNR/DNI, nor a physician order for DNR/DNI. Also, the clinical record contains the following active physician transfusion order dated 9/9/2025 at 10:06 AM but not performed by nursing staff: “transfuse 2 units of packed red blood cells (PRBC)”. 9. The facility did not maintain and demonstrate evidence that, during the admission process, the procedure about how to submit advanced directives is clearly explained to patients or relatives and to have hospital staff and practitioners who provide care in the hospital to comply with these directives.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 47632 Based on observations made in the operating room with the supervisor (employee #23) on 09/09/2025, it was determined that the facility failed to ensure the patient’s physical privacy during nursing treatment. Findings include: 1. During the observation observations carried out in Phase 1 on 09/09/2025, at 9:16 AM, the following was observed: a. The registered nurse (employee #26) was observed attempting to induct an Intravenous- IV catheter into a patient in cubicle #3 without providing privacy.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 51629 Based on interviews with the Quality Improvement Coordinator (employee # 10) and document reviewed performed on 09/9/2025 at 9:00 AM, it was determined that the facility failed to establish a process to protect the right of the patient to be free from all forms of abuse, neglect and harassment. Findings include: 1. During interview with Quality Improvement Coordinator (employee # 10) performed on 09/9/2025 at 9:00 AM, the surveyor request to provide the policy and procedure on Abuse and Neglect, but at the time of the completion of the survey, the document was not provided to the surveyor. 2. During document review performed on 9/11/2025 at 10:00 AM, a document was provided about a conference on the topic of abuse and neglect, but it was only directed at the pediatric population. 3. The facility failed to establish a process to protect the right of the patient to be free from all forms of abuse, neglect and harassment. Also, the facility failed to demonstrate compliance with related state laws and regulations (Law 121 of July 12, 1986 and Administrative Order # 172 of the Department of Health on April 1, 2002).”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 51629 Based on interviews with the Intensive Care Unit Supervisor (employee # 11), document review and records reviewed (RR) performed on 09/10/2025 at 1:30 PM, it was determine that the facility failed to establish a process to protect the right of the patient to be free from restraint and to apply it only when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This deficient practice was identified in 1 out of 1 record reviewed (RR # 22). Findings include: During interview with Intensive Care Unit Supervisor (employee # 11) performed on 09/10/2025 at 1:30 PM, she states that, according to facility policy and procedure, restraint is applied only when there is an imminent danger of the patient to disconnect from vital equipment, hurt himself or others. The facility policy named: Protocolo y Política de Restricción de Pacientes- Protocol and Policy of Patients Restrain (01/2025 effective date), was reviewed on 09/11/2025 at 11:00 AM. The facility policy states that restraint is applied only when there is an imminent danger of the patient to disconnect from vital equipment, hurt himself or others. 1. RR # 22 is a 95-year-old female who was admitted on 9/1/2025 with a diagnosis of Bed Confinement Status. On 9/10/2025 at 10:32 AM, the physician prescribed a telephone order to restrain the upper extremities but did not certify that less restrictive interventions had been determined to be ineffective. 2.The facility failed to document alternatives attempted before the order of restraint.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 51629 Based on interviews with the Discharge Planning coordinator (employee # 20) performed on 09/11/2025 at 11:00 AM, Registered Nurse of the Discharge Planning service (employee # 21) and document review performed on 09/11/2025 at 8:30 AM, it was identified that the facility failed to develop, implement and maintain an effective, ongoing, data-driven Quality Assessment and Performance Improvement Program- QAPI for discharge planning program and Anesthesia Services.. Findings include: 1. During interview with the Registered Nurse of the Discharge Planning service (employee # 21) and document review performed on 09/11/2025 at 8:30 AM, she stated that they maintain statistics and tables with the record of all patients treated but did not provide quality indicators on aspects to be monitored. 2. During interview with the Discharge Planning coordinator (employee # 20) and document review performed on 09/11/2025 at 11:00 AM, no information was provided about quality indicators on aspects to be monitored, including the delivery of Medicare Important Message 2 days prior to discharge. The facility did not maintain and demonstrate evidence of its QAPI for the Discharge Planning Program. 47632 3. During the interview with the lead anesthesia nurse (employee #28) on 09/10/2025 at 9:40 AM, who started at Anesthesia Professional Group in February 2025, she stated that they do not have a quality meeting, anesthesia indicators in the anesthesia area. The administrator (employee #4) was requested on 09/10/2025 at 1:45 PM, of the anesthesia department policies and procedures manual, indicators, or an educational plan. He submitted the policies and procedures manual, which lacks structure.”

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 20423 Based on twenty-two physician credential files reviewed, it was determined that the facility failed periodically to conduct appraisals of its member of the medical staff for 11 out of 22 physician credential files (PCF). P.C.F #6, 7, 8, 10, 11, 12, 14, 15, 16, 17 and #18. Findings include: During the review of twenty-two physician credential File (P.C.F) with the administrator employee #4, it was found the following: The Medical staff bylaws, rule and regulator was reviewed on 09/10/2025 at 10:00 am provided evidence that was reviewed and approved by the Board Director on 04/02/2024. It establish in page 9 Section D Term of Appointment establish Medical & AHP staff appointment and reappointment shall be for no more than two (2) years. 1. Eleven out of twenty -two physician credential files provide evidence that the physician privileges were expired as follows: a. P.C.F #6 provide evidence that the privileges expired on 06/30/2025. b. P.C.F #7 provide evidence that the privileges expired on 03/30/2025. c. P.C.F #8 provides evidence that the privileges expired on 09/01/2025. d. P.C.F #10 provide evidence that the privileges expired on 06/30/2025. e. P.C.F #11 provide evidence that the privileges expired on 06/30/2025. f. P.C.F #12 provide evidence that the privileges expired on 06/30/2025. g. P.C.F #14 provide evidence that the privileges expired on 06/30/2025. h. P.C.F #15 provide evidence that the privileges expired on 01/29/2025. i. P.C.F #16 provide evidence that the privileges expired on 01/29/2025. j. P.C.F #17 no evidence was found of the privileges. k. P.C.F #18 provides evidence that the privileges expired on 06/30/2025. 2. No evidence was found that physician privileges were in the process of reappointment by the facility Governing body.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 20423 Based on twenty-two Physician Credential File (P.C.F.), it was determined that the facility Medical Staff failed to ensure that elegible candidate for the medical staff membership maintaining updated credential related to Cardiopulmonary resuscitation (CPR) Certification, State Narcotic License, Mal Practice Insurance, Hepatitis B Vaccine, Influenza Vaccine, Covid 19 vaccine, Health Certificate, Criminal record, and updated privilege for 22 out of 22 physician Credential File (P.C.F). Findings include: 1. During the review of 22 Physician Credential File with the administrator employee #4 it was found the following: a. Thirteen out of twenty-two physician Credential File did not have an updated CPR as follows: -P.C.F #1, the Basic Life Support (BLS) Certification was an online Certification and the Advance Cardiac Life Support (ACLS) Certification expired on 05/2025. -P.C.F # 2, the BLS certification was an online Certification and expired 2017. -P.C.F #3, the BLS Certification expired on 10/2021. -P.C.F #4, the ACLS Certification expired on 08/2024. -P.C.F #5, the ACLS Certification expired on 04/2025, and the Pediatric Advance Life Support (PALS) Certification expired 07/2024. -P.C.F #6, the BLS Certification expired on 03/2025. -P.C.F #7, the BLS Certification expired on 09/2022. -P.C.F #8, the BLS Certification expired on 05/2019 and the ACLS Certification expired on 06/2025. -P.C.F #11, the BLS Certification expired on 06/2025 and the ACLS Certification was online certification and expired on 12/2024. -P.C.F #12, the ACLS Certification expired on 08/2025, and the PALS Certification expired 08/2025. -P.C.F # 13, the ACLS Certification expired in 2021. -P.C.F #14, the BLS Certification expired on 06/2025, the ACLS Certification expired on 06/2025, and the PALS Certification expired 01/2025 . -P.C.F #16, did not have evidence of an updated CPR Certification. -Physician Assistance C. F #21 and #22, did not have evidence of an updated CPR Certification. b. One out of twenty-two physicians, Credential File did not have an updated Federal Narcotic License as follows: -P.C.F #15, did not have evidence of Federal Narcotic License. c. One out of twenty-two physicians, Credential File did not have an updated State Narcotic License as follows: -P.C.F #2, did not have evidence of State Narcotic license expired on 02/28/2025. d. Five out of twenty-two physician Credential File did not have an updated Mal-Practice Insurance as follow: -P.C.F #12, did not have evidence of updated Mal-Practice Insurance expired on 08/26/2023. -P.C.F #14, did not have evidence of updated Mal-Practice Insurance expired on 08/03/2025. -P.C.F #15, did not have evidence of updated Mal-Practice Insurance expired on 07/16/2025. -P.C.F #17, did not have evidence of updated Mal-Practice Insurance expired on 08/15/2025. -P.C.F #20, did not have evidence of updated Mal-Practice Insurance. e. Ten out of twenty-two physician Credential File did not have evidence of the Hepatitis B Vaccine or Hepatitis B title as follow: -P.C.F #3, did not have evidence of the Hepatitis B Vaccine or Hepatitis B title -P.C.F #5, did not have evidence of the Hepatitis B Vaccine or Hepatitis B title . -P.C.F #7, did not have evidence of the Hepatitis B Vaccine or Hepatitis B title . -P.C.F #8, did not have evidence of the Hepatitis B Vaccine or Hepatitis B title . -P.C.F #11, did not have evidence of the Hepatitis B Vaccine or Hepatitis B title . -P.C.F #13, did not have evidence of the Hepatitis B Vaccine or Hepatitis B title . -P.C.F #16, did not have evidence of the Hepatitis B Vaccine or Hepatitis B title . -P.C.F #17, did not have evidence of the Hepatitis B Vaccine or Hepatitis B title . -P.C.F #18, did not have evidence of the Hepatitis B Vaccine or Hepatitis B title . -P.C.F #20, did not have evidence of the Hepatitis B Vaccine or Hepatitis B title . f. Fifteen out of twenty-two physician Credential File did not have evidence of update Influenza Vaccine or refuses as follow: -P.C.F #1, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #2, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #3, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #5, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #6, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #7, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #8, did not have evidence of update Influenza Vaccine or refuses . -P.C.F #9, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #11 did not have evidence of update Influenza Vaccine or refuses. -P.C.F #12, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #13, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #14, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #16, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #19, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #20, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #21, did not have evidence of update Influenza Vaccine or refuses. -P.C.F #22, did not have evidence of update Influenza Vaccine or refuses. g. Eleven out of twenty-two physician Credential File did not have evidence of Covid 19 Vaccine or refuses as follow: -P.C.F #1, did not have evidence of Covid 19 Vaccine or refuses . -P.C.F #2, did not have evidence of Covid 19 Vaccine or refuses. -P.C.F #3, did not have evidence of Covid 19 Vaccine or refuses. -P.C.F #5, did not have evidence of Covid 19 Vaccine or refuses. -P.C.F #6, did not have evidence of Covid 19 Vaccine or refuses. -P.C.F #8, did not have evidence of Covid 19 Vaccine or refuses . -P.C.F #10, did not have evidence of Covid 19 Vaccine or refuses. -P.C.F #16, did not have evidence of Covid 19 Vaccine or refuses. -P.C.F #17, did not have evidence of Covid 19 Vaccine or refuses. -P.C.F #18, did not have evidence of Covid 19 Vaccine or refuses. h. Ten out of twenty-two physician Credential File did not have evidence of updated Health Certification as follows: -P.C.F #3, did not have evidence of updated Health Certification expired on 11/06/2024. -P.C.F #5, did not have evidence of updated Health Certification. -P.C.F #7, did not have evidence of updated Health Certification expired on 07/14/2023. -P.C.F #11, did not have evidence of updated Health Certification expired on 08/31/2024. -P.C.F #12, did not have evidence of updated Health Certification expired on 08/16/2024. -P.C.F #13, did not have evidence of updated Health Certification expired on 06/12/2025. -P.C.F #14, did not have evidence of updated Health Certification expired on 06/21/2024. -P.C.F #16, did not have evidence of updated Health Certification. -P.C.F #17, did not have evidence of updated Health Certification. -P.C.F #20, did not have evidence of updated Health Certification expired on 07/31/2018. i. Ten out of twenty-two physicians, Credential File did not have evidence of updated Criminal Record as follows: -P.C.F #2, did not have evidence of updated Criminal Record Certification expired on 02/21/2019. -P.C.F #3, did not have evidence of updated Criminal Record Certification expired on 1/23/2024. -P.C.F #4, did not have evidence of updated Criminal Record Certification expired on 04/17/2024. -P.C.F #5, did not have evidence of updated Criminal Record Certification. -P.C.F #6, did not have evidence of updated Criminal Record Certification expired on 04/18/2024. -P.C.F #8, did not have evidence of updated Criminal Record Certification expired on 02/06/2023. -P.C.F #9, did not have evidence of updated Criminal Record Certification expired on 08/01/2024. -P.C.F #16, did not have evidence of updated Criminal Record Certification expired on 10/03/2023. -P.C.F #20, did not have evidence of updated Criminal Record Certification expired on 06/23/2023. 2. According to the “Bylaws” established that professional qualifications are required.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 17959 Based on seventy-six clinical records reviewed (R.R), it was determined that the facility failed to ensure that the patient medical records contain complete information and documentation regarding evaluations, interventions, care provided, services, for 11 out of 80 records reviewed (R.R #13, #15, #20, #68, #69, #70, #71, #72 #73, #74 and #75). Findings include: A. Eleven out of seventy six clinical records reviewed (R.R. #13, #15, #20, #68, #69, #70, #71, #72, #73, #74 and #75 during the recertification survey performed from 9/9/2025 through 9/11/2025 did not contain complete information and documentation related to: Vital sings in the Pre-anesthesia evaluation, Transfusion Consult lacks date and hour, signature of the patient ‘s representative, consults, registration certification, discharge certification, discharge summary, physician license number, condition of patient on transfer and discharge lacks of hour, consent form anesthesia services only initials does not indicate if you are a doctor or nurse and no anesthesiologist’s license number, transfer and discharge, consult report, cardiology consult and pneumology consult in blank, infection consult lacks of physician signature, treatment consent, anesthesia consent lacks of physician signature, date and hour, physician history and physical examination, anesthesia records, post anesthesia follow up, physician’s orders. 1. Record #13 is an 87-year-old female who was admitted on 08/04/2025 at 6:42 AM to the operating room department with a diagnosis of Left Leg DSA Possible ATX to performed Invasive Study. a) During the record review performed on 09/09/2025 at 10:30 AM, the Pre-OP time out checklist the nursing did not identify with (RN #36) the surgery procedure performed by the physician. Lacks physician and nursing license number. The Anesthesia, Pre-Anesthesia Evaluation on the area referred ’ To be checked day of Surgery the area designated to vital signs was maintained in blank for B/P, Pulse and temperature. Lacks the physician signature and license number. The Arteriogram Report and Risk assessment of ulcers or pressure points was maintained in blank. 2. Record #15 is a 32-year-old male who was admitted on 06/02/2025 at 11:40 AM to Right foot debridement. Information form on anesthesia services and consent form was maintained in blank. The condition of patient on transfer / discharge signed by the anesthesiologist on 06/03/2025 lacks of the hour. 3. Record #20 is a 32-year-old male with diagnosis of Left DR Fracture and received PRBC on 05/09/2025 at 6:10 AM the requisition for dispatch of blood components after finishing transfusion the area that indicates if there was a reaction to transfusion was not evaluated by nursing staff remains blank. 4. Record #68 is a 79-year-old female with diagnosis of Venous insufficiency. According to the patient orientation form the procedure Aorto Vac and Right DSA was on 01/20/2025 at 6:00 AM. The form to identify risk assessment of ulcers or pressure pulses made on 01/20/2025 is signed but has a nurse license number. The Anesthesia, Pre-Anesthesia Evaluation form was maintained in blank. The Evaluation and Transfer / Discharge Note , Observations / Precautions, the date and hour were maintain in blank. Services and consent information form signed by the patient missing the hour. The Anesthesia , Pre-anesthesia evaluation missing the anesthesiology signature. Nursing department operating room, the pre-operative estimate is in blank. Pre-OP time out checklist Nursing department lacks date, physician and nursing signature and license number. Intraoperative nursing note and Anesthesiologist Condition of patient on transfer / Discharge is in blank. Consultation Request to Infection Disease and Endocrinology lacks the hour, date and no evidence of report. Consultation report to PMR lack hour, date, report requested regarding and signature of attending physician. 5. Record #69 is a 75-year-old female with surgical procedure of Left catheterization possible Angioplasty. The Consent form special surgical procedures signed by patients missing date and time of signature. Missing of the name and signature of the anesthesiologist, date and time. Anesthesia, Pre-Anesthesia Evaluation performed on 01/22/2025 at 10:00 AM maintain blank spaces and lacks physician signature, date and hour. The Condition of Patient on Transfer / Discharge, Observations / Precautions, date, hour and Anesthesiologist signature was maintained in blank. Consultation Request to Cardiology team lacks the hour, date, the consult was left in blank. 6. Record #70 is an 89-year-old female with Dx. Cholelithiasis, BKP/Pulmonary Edema, history of Colon Cancer. Consultation Request to Pneumology, Cardiology, Gastroenterology, Nutritionist and Infectiology lacks the hour and date when solicited the service and the consult was left in blank. 7. Record #71 is a 92-year-old male with Dx. Sepsis / Metabolic Acidosis. The Doctor’s certification related to cardiopulmonary resuscitation measures signed by the doctor on 02/06/2025 missing name of the witness relationship and signature. Consent form Surgical or Special Procedures missing signature of the doctor, license number, date and time. Consultation Request to Nutritionist, Pneumology, Cardiology and physician to evaluate for Central Line lacks the hour and date when the service was requested and the consults was left in blank. 8. Record #72 is a 76-year-old male with Dx. Left BKA Debridement. The form Condition of Patient on Transfer / Discharge performed on 05/12/2025 missing the time. 9. Record #73 is an 82-year-old female with Dx. COPD Exacerbation. Consultation Request to Pneumology lacks the time, date, the consult was in blank. Patient satisfaction questionnaire in blank and Nursing discharge note in blank. 10. Record #74 is an 89-year-old female with Dx. Symptomatic Anemia received two transfusions 04/05/2025 and 04/06/2025, however the Information and consent form on blood transfusions and / or blood derivate products non-specific procedure to be carried out. 11. Record #75 is a 35-year-old female with Dx. Buttock RE Shaping and Brea. the form Condition of Patient on Transfer / Discharge lacks information if the patient is good, Fair or Poor. The designated area to evaluate and transfer / Discharge notes, Observations / Precautions, date and hour was maintained in blank. Intraoperative nursing note lacks Nursing Relay Signature and license number. Anesthesia and Pre-Anesthesia Evaluation performed on 3/21/2025 at 10:30 AM missing the physician license number. Elective cases collation sheet performed on 4/4 2025 missing the name and the license number of the nurse who delivers and the one who receivers.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 51782 Based on close, active and transfer clinical records reviewed (R.R) from 09/09/2025 through 09/11/2025, it was determined that the facility failed to ensure that all patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedure, related to lack of documentation of vital signs on the transfer document 5 out of 80 Records Review (RR . #45, #46, #47, #49, and #59#). Findings include: Facility policy provided by Emergency Room Supervisor (employee #5), on 09/11/2025 at 12:42 PM was reviewed. The policy was reviewed on 01/01/2025, Traslado de Pacientes desde Sala de Emergencias hacia otras instituciones hospitalarias- Transfer of Patients from Emergency Room to other Hospital Institutions. The policy states on page 2, section 11 that the method of transfer is documented in the Electronic Health Record-EHR. 1. R.R #59 is a 92-year-old female who was admitted on 09/05/2025 to the emergency room (ER) with a diagnosis of Right Lower Abdominal Pain who transferred to another institution hospital in Caguas due to diagnosis of Ureterolithiasis. a) During the record review performed on 09/10/2025 at 9:15 AM, in the patient transfer note to another institution, the doctor left the vital signs area in blank. 47632 2. R. R #45 is a 16-year-old female admitted to facility on 05/27/2025 with Rhinoplasty. During the record review performed on 09/10/2025 at 11:10 AM, the following was found: a. The absence of the anesthesiologist’s signature on the transferred patient’s status sheet or on the discharge sheet. 3. R. R #46 is a 95-year-old female admitted to facility on 01/16/2025 with Excision debridement of right above knee stump. During the record review performed on 09/10/2025 at 9:09 AM, the following was found: a. The absence of the date and time of the nursing staff in the intraoperative note. b. The absence of the date and time after the patient’s representative signed. c. The absence of date, time, and the anesthesiologist’s signature on the anesthesia consent form. d. Absence of type of anesthesia, premedication, and signature of the anesthesiologist. e. The absence of patient status and education on the preoperative sheet by the nursing staff. f. The condition sheet of the transferred or discharged patient was not completed. 4. R. R #47 is a 76-year-old male admitted to facility on 02/03/2025 with Left heart catheterization. During the record review performed on 09/10/2025 at 10:04 AM, the following were found: a. The absence of education, date and signature by the nursing staff on the preoperative assessment sheet. 5. R. R #48 is a 39-year-old male admitted to facility on 02/24/2025 with Repair incarcerated abdominal wall and groin hernia with mesh. During the record review performed on 09/10/2025 at 10:04 AM, the following were found: a. The pre-anesthetic evaluation sheet noted a lack of the type of anesthesia for the patient and pre-medication. b. The absence of the anesthesia nurse signature on the second intraoperative anesthesia sheet. c. The absence of time in the medications administered, mark the surgical site, whether the materials count was complete or incomplete and whether the patient was transported to recovery I or II on the preoperative nursing estimate sheet. d. The absence of date and time and disposition of the anesthesiologist in the status sheet of the transferred or discharged patient. e. The absence of the type of anesthesia and signature of the anesthesiologist would be used in the consent form for anesthesia services. 6. R.R #49 is a 60year old male admitted to facility on 03/19/2025 with Percutaneous coronary steent placement. During the record review performed on 09/10/2025 at 10:24 AM, the following was found: a. The absence of the anesthesiologist’s signature and the type of anesthesia on the anesthesia consent form. b. The absence of time by the nursing staff in the intraoperative nursing note. c. The absence of time by the anesthesiologist in the condition sheet of the transferred or discharged patient. d. An unsigned cardiovascular admission order was observed, with no date or time provided by the nursing staff.”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 51629 Based on interviews with the Intensive Care Unit Supervisor (employee # 11), document review and records reviewed (RR) performed on 09/10/2025 at 1:30 PM, it was determined that the facility failed to execute informed consent forms for procedures and treatments specified by medical staff, or by federal or state law if applicable, to require written patient consent. This deficient practice was identified in 3 out of 80 records reviewed (RR. #22, #56 and # 71). Findings include: Records reviewed with Intensive Care Unit Supervisor (employee # 11) was performed on 09/10/2025 at 1:30 PM. 1. RR # 22 is a 95-year-old female who was admitted on 9/1/2025 with a diagnosis of Bed Confinement Status. On 9/2/2025 at 8:00 AM, a surgery consent form was documented, signed and dated by the surgeon and patient representative. The document states that the patient was going to undergo the following surgery: Aortoiliac arteriogram on the left leg with possible revascularization. The clinical record includes an anesthesia permission form called: “Formulario de Información sobre Servicio de Anestesia y Formulario de Consentimiento”. It is signed by the patient’s representative but not dated, nor signed and dated by the anesthesiologist. 2. RR # 56 is a 96-year-old male who was admitted on 09/04/2025 with a diagnosis of DSA possible ATX. On 9/9/2025 at 10:20 AM, a surgery consent form was documented, signed and dated by the patient representative but not signed nor dated by the surgeon. It states that the patient was going to undergo the following surgery: Left leg revascularization. 3.The facility failed to execute informed consent forms for procedures and treatments. 17959 4. Record #71 is a 92-year-old male with Dx. Sepsis / Metabolic Acidosis. The Doctor’s certification related to cardiopulmonary resuscitation measures signed by the physician on 02/06/2025 is missing name of the witness relationship and signature. Consent form Surgical or Special Procedures missing signature of the doctor, license number, date and time. Consultation Request to Nutritionist, Pneumology, Cardiology and physician to evaluate for Central Line lacks the hour and date when the service was requested and the consult was left in blank.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 51782 Based on observations conducted in the Emergency Room Department, performed on 09/09/2025 through 09/11/2025 to from 8:30 AM through 3:30 PM, it was determined that the facility failed to ensure all drugs and biologicals must be kept in a secure area, locked when appropriate related to nebulizer therapy medications, stored on the emergency room shelf and operating room. Findings include: 1. During observations conducted in the Emergency Room respiratory therapy supplies and medications area, on 09/09/2025 from 9:00 AM through 11:00 AM with Emergency Room Supervisor (employee #5) and Respiratory Therapy Supervisor (employee #6) the following was observed: a) At 10:10 AM, a shelf of nebulizer therapy medications was observed in the emergency room, accessible with the door unlocked. 2. During observations conducted in the Emergency Room Department fast track area with Physical Plant Manager (employee #33) and Emergency Room Supervisor (employee #5), on 09/10/2025 from 1:00 PM to 1:30 PM, the following was observed: a) At 1:06 PM, the fast-track area of the emergency room was observed to have the medication room door open, held by a sharp container and unsafe with injectable medications such as Ketorolac 30mg per ml and Ketorolac 60mg per 2ml with the door open. 47632 3. During observations conducted with the operating room supervisor (Employee #23) on 09/09/2025 at 9:24 AM, high-risk medications were found in the nursing counter area, along with the first door containing the narcotics. These medications were found accessible to any staff member or patient. The administrator (employee #4) was informed on 09/10/2025 at 3:00 PM about the exposed medications. He responded immediately and requested a secure medication cart to store them. On 09/11/2025 at 8:13 AM, high-risk medications were observed stored on the medication cart.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 51782 Based on observations conducted in the Emergency Room Department, review the policies, and staff interviews performed on 09/09/2025 through 09/11/2025 to from 8:30 AM through 3:30 PM, it was determined that the facility failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use related to opened multi-use dose medications without an opening date and medications with an expiration date. (Cross Reference Tag A0749). Findings include: Facility policy provided by Emergency Room Supervisor (employee #5), on 09/10/2025 at 9:09 AM was reviewed “Medicamentos en Envase de Uso Múltiple”. The policy states on page 129, section 6 that they are labeled “Date Vial Open,” where the nurse will note the date the bottle was first used. The expired vial will be returned to the Clinical Pharmacy as surplus. 1. During observations conducted in the Emergency Room medication area, on 09/09/2025 from 9:00 AM through 11:00 AM, with Emergency Room Supervisor (employee #5) the following was observed: a) At 10:32 A.M one activated Charcoal suspension 25gm, it was observed in the antidote tray expired on 08/2025. b) At 10:40 A.M., one bottle of Labetalol Hydrochloride injection 100mg per 20ml, it was observed open without opening date. c) AT 10:51 AM one bottle of Mineral Oil Lubricant Laxative, it was observed open without opening date. d) AT 10:52 AM one bottle of Mineral Oil Lidocaine Hydrochloride oral 2% (viscous), it was observed open without opening date. e) At 10:53 AM one bottle of Milk of Magnesia saline laxative, it was observed open without opening date. 2. During observations conducted in the Emergency Room respiratory therapy supplies and medications area, on 09/09/2025 from 9:00 AM through 11:00 AM, with Emergency Room Supervisor (employee #5) and Respiratory Therapy Supervisor (employee #6) the following was observed: a) At 10:10 A.M fourteen packages of Albuterol Sulfate inhalation solution 2.5mg/3ml Lot 421131, it was observed expired on 08/2025.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 51637 Based on observations, interviews and documents reviewed, it was determined that the facility failed to ensure that the kitchen staff complies with the kitchen standards regarding the disinfection and temperature measurement of the water when washing the trays and utensils. Findings include: The facilitys’ policies named “Lavado y Esterilización de Bandejas Termales” y “Fregado de Ollas, Calderos y Utencilios de Cocina” were reviewed on 09/09/2025 at 2:30pm and stated that the tray must have a 140 gradeº Fahrenheit- (F) temperature in the first cycle, 160º F temperature in the second cycle and 180º F temperature in the third cycle. The first compartment of the utensils wash, should have a temperature of 110º F, the second compartment should have a temperature of 120º F, and the third compartment should have a temperature of 170º F. 1. During the kitchen tour performed on 09/09/2025 from 9:00am till 11:30am accompanied by the kitchen supervisor (employee #2) the following was observed: a) In the sink area of the three compartments where the trays are washed and where the kitchen utensils are washed, there is no evidence of the temperature of the water at the time of washing. 2. During the interview conducted with employee #2 on 09/10/2025 at 10:15 a.m., she stated that the process of taking the temperature of the water from the three-compartment sinks was not being performed.”

“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: 51637 Based on facility tour performed on 09/09/2025 from 8:00am till 11:30am, it was determined that the facility failed to maintain facility in such a manner that the safety and well-being of patients are assured. Findings include: 1. During the kitchen tour performed on 09/09/2025 from 9:00am till 11:30am accompanied by the kitchen supervisor (employee #2) the following was observed: a) Roof acoustics with noticeable appearance of humidity and filtration. b) Employee’s #2 office wall had leak marks and bubbles on the paint with noticeable water retention. 17959 2. During the Medical Record Archivo General- General Storage tour located in the basement of the hospital perform on 09/09/2025 from 9:05 AM till 11:30 AM accompanied by the Information Management Manager (employee #35) the following was observed: a) Has two aluminum doors with regular locks, the door located at the Emergency Exit that goes out to the stairs was found closed but unlocked. b. Lacks Sprinkles and Fire Extinguisher on the interior. One Extinguisher was observed at the end of the corridor that goes out to the Emergency staircase, it has no evidence of monthly check - up tags. c. Did not have ‘Sprinkler ’ on the interior of the area. d. Roof acoustics with noticeable appearance of humidity and filtration, brown stains were observed. e. No Emergency lights on the interior of the medical record storage. f. Approximately thirty boxes and loose papers were observed on the left side of that faces the emergency staircase which was found without the lock. Other boxes contain patient records and plastic bags with Christmas items were observed on the back of the file shelves. 51782 3. On 09/09/2025 at 8:55 AM; abundant dust particles like were observed in the ventilation air return located in the emergency room in the waiting room. 47384 During observations and interviews made with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), the following was noticed. A. Water stained in the following areas: 1. Stetic warehose on the Surgery Department 2. Supervisor office in the kitchen area 3. General supply warehouse 4. Mechanical room 5. Manager office on the Billing Department 6. Managers office on the Laboratory Department B. Walls with black mold like stains in the following areas: 1. Supervisor office in the kitchen area 2. General supply warehouse C. The boiler rooms in the auto key area and the basement boiler area were checked, and in both areas, the corresponding certification for Regulation #17 of the Puerto Rico Department of Labor could not be identified. They were requested from the Physical Plant Supervisor and the Project Manager, and at the time of the survey’s completion, they were not provided.”

“EMERGENCY POWER AND LIGHTING CFR(s): 482.41(a)(1) There must be emergency power and lighting in at least the operating, recovery, intensive care, and emergency rooms, and stairwells. In all other areas not serviced by the emergency supply source, battery lamps and flashlights must be available. 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 Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to maintain the generator or other alternate power source and associated equipment to supply service within 10 seconds, which resulted on an Immediate Jeopardy. Findings include: On 9/9/2025 at 10:00 am a Puerto Rico Power Authoirty (LUMA) power outage occurs, alternative power (generator) was recovered 37 seconds after the event. During the 37 seconds that the facility was without power (neither from the power grid nor the generator) employees were observed holding cellular phone light to during procedures being performed in the surgical suites #1 and #6. Also complete hallways were observed with no emergency light functioning on the Surgery Department. Approximately at 1:41 PM the facility’s Project Manager request that the surveyor visit the the generators and the transfer switch area. The external company that provides service to the Hospital had completed the reprogramming process for both the three generators and the transfer switch. A test was conducted in the presence of the surveyor during which the facility was disconnected from the power grid and the generators started up in 8 seconds. The Facility provided the plan of correction at 2:52 PM A. TAG K918 Electrical Systems - Essential Electric System Maintenance and Testing B. Plan for correcting the deficiency 1) The Physical Plant Supervisor immediately contacted the power generator maintenance contractor (Today Smart Energy). 2) Technician updated the system programming and conducted tests in presence of surveyor LSC Lead Surveyor (See.Attachment 1). 3) During testing, generator start time was measured at three seconds. 4) During testing, the transfer load time was measured at eight (8) seconds. 5) The system was determined to be compliant with NFPA 110 standard. 6) The emergency light in the OR was replaced and observed to function properly. C. Plan for improving the process 1) The hospital has contracted the services of an independent firm to assist hospital personnel in conducting tests for maintaining compliance. 2) The system was determined to be compliant with NFPA 110 standard. E. Procedure for implementation 1) The physical plant has determined to update the testing schedule. 2) The hospital has contracted a firm to monitor compliance with transfer time. F. Tracking Procedure The hospital has contracted the services of an independent firm to assist hospital personnel in conducting tests for maintaining compliance. The maintenance schedule will include verification of transfer time metrics for assessment. G. Responsible Individuals 1) Department Supervisor 2) Physical Plant Director 3) Hosp. Administrator Completion date 09/09/2025 Surveyor accepted plan at 2:55PM.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for Life Safety from Fire of the Hospital with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), 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 09/09/2025 through 09/11/2025 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 2567 form (K211, K222, K225, K281, K291, K293, K321, K323, K324,K342, K345, K351, K353, K355, K363, K712, K751, K761, K781, K904, K907 AND Tag K918).”

“ALCOHOL-BASED HAND RUB DISPENSERS CFR(s): 482.41(b)(9) (7) A hospital may install alcohol-based hand rub dispensers in its facility if the dispensers are installed in a manner that adequately protects against inappropriate access; This Standard is not met as evidenced by: 47632 Based on observations made in the operating room with the operating room supervisor (employee #23) from 09/09/2025 to 09/10/2025 at 8:00 AM to 3:00 PM, it was determined that the facility failed to have alcohol-based hand sanitizer dispensers available to staff in 9 out of 9 operating rooms. Findings include: During observations in nine of the nine operating rooms, staff did not have access to hand sanitizers. During the procedure, it was observed that staff did not clean their hands with alcohol after disposing of gloves due to a lack of hand sanitizer.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 15884 Based on observations, and facility staff interview performed on 09/10/2025 through 09/11/2025 to from 8:30 am through 4:00 pm, it was determined that the facility failed to ensure that facility and equipment is maintained to ensure an acceptable level of safety and quality and appropriate electrical devices are used to ensure patient safety and reliable power. Findings include: During the radiology department survey procedures with X Rays department supervisor (employee # 8) on 09/10/2025 from 8:30 am through 11:00 am the following findings were identified: 1. Radiology department defibrillator did not have the inspection label of the biomedical services. 2. The surveyor asked the Radiology department supervisor ( employee # 8 ) on 09/10/2025 from 9:00 am if the equipment had been inspected by the biomedical services personnel. The Radiology department supervisor ( employee # 8 ) stated in an interview on 09/10/2025 from 9:10 am that she does not know if this equipment had been inspected. 3. Two regular multiplug receptacles were observed to be used in the X rays’ room #2. 4. One regular multiplug was observed being used in the area where personnel put to charge the Radiology portable equipment cassettes. 5. At the Computer Tomography room, it was observed a red and black regular long cord extension. The Radiology department supervisor ( employee # 8 ) stated in an interview on 09/10/2025 from 9:55 am that the red and black regular cord extension is used in the computer tomography room when the table does not adjust to a specific patient stretcher. 51782 Facility policy provided by Emergency Room Supervisor (employee #5), on 09/10/2025 at 8:54 AM was reviewed. “Disponibilidad del Intercomunicador de Enfermería (Nurse Call) para Pacientes”. The policy states on page 1, section 2 that it must be located on one of the sides of the stretcher with the flexibility that the patient can access it without any difficulty. 6. During the round made with the Emergency Room Supervisor (employee # 5) in the emergency room department performed on 09/09/2025 at 9:00 AM to 4:00 PM, the following was observed: a) At 11:01 AM; the nurse call button cable was not accessible to the patient in the following rooms (#6, #7, and #10), which compromised patient safety. 7. At 9:40 AM and 10:00 AM; the defibrillator monitor on the adult and pediatric emergency cart of emergency room department is observed to have no inspection seal. During an interview with the emergency room supervisor (employee #5), she makes a phone call to the biomedical personnel who mentions that they are in the process of hiring an external company to perform the inspection. 47632 8. During the observations carried out in Phase #1 with the supervisor (employee #23) on 09/09/2025 at 9:20 AM, the following was found: a. A vital signs machine was observed; inspection was 12/2023. 9. During observations made in the recovery with the supervisor (employee #23) on 09/09/2025 at 9:34 AM, the following was found: a. Twelve of twelve cardiac monitors were observed with expired inspections as of 12/2023. b. Uncovered receptacles were observed in electrical outlets. c. Sharp counterainer filled over capacity 10. During observations carried out in the isolation area with the supervisor (employee #23) on 09/09/2025 at 10:03 AM, the following was found: a. A warmer was observed without an inspection date. 11. During observations made on the emergency car in the operating room with the supervisor (employee #23) on 09/09/2025 at 1:18 PM, the following was found: a. Two of two defibrillators in the emergency car without inspection expired on 02/2024. 12. During observations made in the operating room with the supervisor (employee #23) on 09/09/2025 at 8:00 to 2:00 PM, the following was found: Recovery area: a. The wall oxygen valves were observed without inspection. Hall operating room: a. The UPC machine room was observed, and medical equipment was found in the electrical room. Room #9 Emergency cart: a. Electrodes expired on 02/20/2023. b. Seven purple EDTA tubes expired on 05/30/2025. c. Seven green tubes expired on 06/30/2025. d. Seven blue tubes expired on 04/30/2025. e. Three 5 ml syringes with sterile water expired on 04/30/2025. f. Three blood collector sets expired on 04/30/2025. Supplies: a. Six 5 Fr angiographic catheters expired on 08/22/2025 and 08/29/2025. b. Four 4 Fr angiographic catheters expired on 08/15/2025. c. One open Lidocaine 500mg/50ml, undated, with no date, time, or nursing staff signature. d. Forty 3.0 Vicryl sutures expired on 05/31/2025. e. Thirty-seven 5.0 Prolene catheters expired on 08/31/2025. f. Three 3.0 Ethilon catheters expired on 08/31/2025. g. seven angiographic needle #18 expired on 09/06/2025.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 51782 Based on the observational tour in the Emergency Room Department and Respiratory Therapy Department on 09/09/2025 through 9/11/2025 from 8:30 AM to 4:00 PM, it was determined that the facility failed to provide standards for infection control related to preventing and controlling the transmission of infections within the hospital. Findings include: 1. During the round made with the Emergency Room Supervisor (employee #5) in the emergency room department area on 09/09/2025 at 9:00 AM through 10:00 AM, the following was observed: a) At 9:23 AM, in the trauma room #2 on emergency room department, three packaged instruments were observed such as surgical forceps, that were expired between 06/2025 thought 08/2025. b) At 9:25 AM, in the trauma room #2 on emergency room department, three packaged instruments were observed such as surgical forceps were observed without an expiration date and/or date of when they were packaged. 2. During the round made with the Therapy Respiratory Supervisor (employee #6) in the respiratory therapy department area on 09/10/2025 at 10:00 AM through 11:00 AM, the following was observed: a) At 10:30 AM, five adult CPAP / HFOT single limb heated wire breathing system 22mm 1.6m kit expired on 08/01/2025 were observed on the medical-surgical supplies area of the respiratory therapy department. b) At 10:45 AM, five tri-flo suction catheter with control port 5/6 Fr expired on 09/17/2024 were observed on the medical-surgical supplies area of the respiratory therapy department. Facility policy provided by Emergency Room Supervisor (employee #5), on 09/10/2025 at 9:09 AM was reviewed “Medicamentos en Envase de Uso Múltiple”. The policy states on page 129, section 6 that they are labeled “Date Vial Open,” where the nurse will note the date the bottle was first used. The expired vial will be returned to the Clinical Pharmacy as surplus. 3. During observations conducted in the Emergency Room medication area, on 09/09/2025 from 9:00 AM through 11:00 AM, with Emergency Room Supervisor (employee #5) the following was observed: a) At 10:32 A.M one activated charcoal suspension 25gm, it was observed in the antidote tray expired on 08/2025. b) At 10:40 A.M., one bottle of labetalol hydrochloride injection 100mg per 20ml, it was observed open without opening date. c) AT 10:51 AM one bottle of mineral oil lubricant laxative, it was observed open without opening date. d) AT 10:52 AM one bottle of mineral oil lidocaine hydrochloride oral 2% (viscous), it was observed open without opening date. e) At 10:53 AM one bottle of milk of magnesia saline laxative, it was observed open without opening date. 4. During observations conducted in the Emergency Room respiratory therapy supplies and medications area, on 09/09/2025 from 9:00 AM through 11:00 AM, with Emergency Room Supervisor (employee #5) and Respiratory Therapy Supervisor (employee #6) the following was observed: a) At 10:10 A.M fourteen packages of albuterol sulfate inhalation solution 2.5mg/3ml Lot 421131, it was observed expired on 08/2025. (Cross Reference TAG A0505) 47632 5. During observations conducted in recovery area with supervisor (employee # 23) on 09/09/2025 at 9:16 AM, the following was found: a. Nursing counter: Medication refrigerator, the following was observed: - A 100-unit vial of Humulin R opened since 04/15/2025. - A 100-unit vial of Humulin 70/30 opened since 05/19/2025. - Observed opened Diltiazem 125 milligrams (mg)/25 milliliters (ml) single dose stored in refrigerator. 6. During observations conducted in operating room area with supervisor (employee # 23) on 09/09/2025 at 10:47 AM, the following was found: a. Room #4: - Observed open Bupivacaine 150mg/30ml single dose stored without date, time and without staff signature. 7. During observations made in the operating room corridor with supervisor (employee # 23) on 09/09/2025 at 10:57 AM, the following was found: a. Anesthesia supply cart: - A vial Dopamine 400 mg/10 expired 10/10/2022. - Four vials Enalapril 2.5mg/2ml expired 10/10/2022. - A vial Hydralazine 20mg/1ml expired 02/2025. - Seven vials Benadryl 50mg/1ml expired 02/2024. - a vial Metoclopramide 10mg/2ml expired 03/01/2025. 8. During observations made during operating room procedures with supervisor (employee # 23) on 09/09/2025 at 1:57 PM, the following was observed: R. R #64 is a 92-year-old woman admitted for procedure on 09/09/2025 for debridement of the right stump. During observations made during operating room procedures, the following was observed: a. The registered nurse (employee #25) had five opportunities to wash her hands with soap and water or hand sanitizer after discarding her gloves and putting on clean gloves. b. An anesthesia nurse (emploe#27) was observed picking something up from the floor with gloves and continuing to manipulate the patient without changing her gloves. The anesthesia nurse had three opportunities to clean the rubber surface with alcohol from the Diprivan medication.”

“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: 51829 Based on observations, interviews, and a review conducted during the visit to the hospital, the facility did not ensure compliance with best practices for prevention, patient safety, and infection control to prevent and minimize infections. Findings include: 1. On 9/9/2025 at 9:57 a.m., during a facility visit on the fourth floor, the registered nurse (Employee No. 12) was observed wearing artificial nails and/or nail extensions, such as “shellac.” The Director of Nursing (Employee No. 9) was present. 2. During the review, expired medical surgical supplies and medications were identified in several locations. Among the materials identified were: a. On September 9, 2025, at 11:37 a.m., a 7.0 endotracheal tube with an expiration date of 2024 and a 6.0 endotracheal tube with an expiration date of 2021 were identified on the crash cart on the fourth floor. b. On September 9, 2025, at 3:15 p.m., a .9% NSS with an expiration date of April 2025 was identified in the medication room of the Intensive Care Unit. c. On 09/10/2026 at 11:48 am, five blue tubes dated 06/30/2025 and two .9% NSS IVs dated 07/31/2025 were identified on the crash cart on floor #3. In the storage area, 16 culture tubes dated 05/21/2025 were identified. d. In the dialysis room crash cart, a 50mg Tridil in 250ml container dated 07/2025 was identified, along with three packages of sterile #7 gloves dated 04/30/2025 and three packages of sterile gauze dated 06/25/2022. The regulation titled Procedure for the Supply, Inspection, and Handling of Emergency Carts and Transport Cases establishes shared responsibility between the Pharmacy and Nursing departments but does not specify the responsibilities. In interviews conducted on September 9, 2025, at 11:27 a.m., the Director of Nursing (Employee #9) indicated that the crash cart is managed by the Pharmacy and is in charge of its control. The Pharmacy technician (Employee #14) indicated that the crash cart is the responsibility of the pharmacy, and that medications are checked monthly. Although the crash cart contains medical-surgical equipment and supplies, she does not check them. Her responsibility is for the medications and that it is locked. If it is used, they must call the Pharmacy to lock it. e. There is no detailed policy or standard regarding medical-surgical equipment. f. The current policy shows contradictions in terms of clear steps to follow, there is no evidence of a review of medical surgical equipment and supplies, and there is no evidence of a checklist that provides a mechanism to ensure that medical surgical equipment and supplies are inspected. g. They show evidence that the Pharmacy Department has a checklist and reviews medications; however, expired high-risk medications were identified inside the crash cart in the dialysis room. 3. On 9/09/2025 at 10:00 am in room #320B, an “IV stand” for administering intravenous fluids was identified, covered in rust, and the water jet requires the nurse to press it to rinse her hands, causing risk of contamination. 4. During the visit made on 9/10/2025 at 10:00 am with the Infection Control Coordinator (Employee #10) and the Director of Nursing (Employee #9) to different spaces, it was identified: a. At 10:49 am in the morgue, it was identified that although they have the policy and log to document temperature and humidity, they are not doing so. Furthermore, there is no extractor fan. b. At 11:02 am, it was identified that there was no room to store the soiled linens used in the hospital. This room should have negative pressure, the required equipment to measure temperature and humidity, and record them. c. The linens were located in front of the warehouse in the receiving area in unmarked containers, and there was no evidence of staff training to handle them safely, as required for contamination prevention. This open-air space does not guarantee infection control. d. The warehouse showed material on the floor, damaged, deteriorated, and dusty boxes, and a general lack of dust control. During this visit, we were also accompanied by the Infection Control Coordinator (Employee #10), the warehouse staff (Employee #17), and the purchasing supervisor (Employee #18), the person in charge of the warehouse. 47632 5. During observations made in the operating room with the supervisor (employee #23) on 09/09/2025 through 09/10/2025 at 8:00 AM to 3:00 PM, the following was found: a. Room # 2: - Peeling paint was observed on the ceiling. - Anesthesia supply cart was observed with corrosion. - A detached surgical lamp was observed. b. Room #3: - One of nine anesthesia machines were observed to have blood. This observation was made with the lead nurse anesthetist (employee #28). - Three of nine anesthesia machines were observed with adhesive tape attached. - Four mop buckets were observed located in the hallway. c. Room # 4: - 27 Vicryl 3.0 expired on 05/31/2025. - The surgical stretcher’s armrests were observed placed on the floor. - WarmAir with the ducts touching the floor. - Peeling paint was observed on the ceiling. d. Room # 7: - Peeling paint on wall. e. In the recovery area: - The suction machine with dust was observed in the emergency cart. - Ten of ten open respiratory therapy humidifiers placed in cubicles 1 through 10. - Four of four WarmAir with the ducts touching the floor. f. Dirty utility room: - Acoustics with humidity were observed. g. Laundry room: - Brush for cleaning medical instruments in poor condition. h. Autoclave room: - Dusty walls were observed. - Walls with peeling paint were observed. - Acoustics with humidity were observed. - Air fans were observed with dark spots. i. Operating room hallway: - Three mop buckets were observed located in the operating room hallway.”

“IC PROFESSIONAL RESPONSIBILITIES POLICIES CFR(s): Standard: Leadership responsibilities (2) The infection preventionist(s)/infection control professional(s) is responsible for: (i) The development and implementation of hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 51829 Based on interview conducted with the Infection Control Coordinator (Employee #10) and review of infection control-related documents, the entity failed to develop and implement hospital-wide prevention and control policies and procedures that adhere to recognized guidelines. Findings include: An interview conducted on 10/09/2025 at 10:00 a.m. with the Infection Control Coordinator, stated that mask fit testing is not being performed on staff as required by OSHA, therefore, no evidence can be provided.”

“IC PROFESSIONAL TRAINING CFR(s): [The infection preventionist(s)/infection control professional(s) is responsible for:] (iv) Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of infection prevention and control guidelines, policies, and procedures. This Standard is not met as evidenced by: 47632 Based on the interview conducted with the operating room supervisor (employee #23) on 09/11/2025, it was determined that the facility failed to ensure that staff and employees providing contracted services at the hospital were educated on infection prevention, control guidelines, policies, and procedures. Findings include: During the interview with the Lead Anesthesia Nurse (employee #28) on 09/11/2025 at 9:40 AM, he stated that during his time as supervisor, he had only trained staff verbally. The supervisor was unable to provide any evidence of having trained staff during 2024 to 2025.”

“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 conducted in the operating room from 09/10/22025 to 09/10/2025, it was determined that the facility failed to ensure the inspection, testing, and maintenance of medical equipment. Findings include: 1. During observations conducted in the operating room, the following were observed: a. Phase 1: A vital signs machine was observed; inspection was 12/2023. b. Recovery: Twelve of twelve cardiac monitors were observed with expired inspections as of 12/2023. c. Isolation Area: A warmer was observed without an inspection date. d. Two of two defibrillators in the emergency car without inspection expired on 02/2024. e. Recovery: The wall oxygen valves were observed without inspection.”

“ORGANIZATION OF ANESTHESIA SERVICES CFR(s): 482.52(a), (c) The organization of anesthesia services must be appropriate to the scope of the services offered. Anesthesia must be administered only by: (1) A qualified anesthesiologist; (2) A doctor of medicine or osteopathy (other than an anesthesiologist); (3) A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under State law; (4) A certified registered nurse anesthetist (CRNA), as defined in §410.69(b) of this chapter, who, unless exempted in accordance with paragraph (c) of this section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed; or (5) An anesthesiologist’s assistant, as defined in Sec. 410.69(b) of this chapter, who is under the supervision of an anesthesiologist who is immediately available if needed. State Exemption (1) A hospital may be exempted from the requirement for MD/DO supervision of CRNAs as described in paragraph (a)(4) of this section, if the State in which the hospital is located submits a letter to CMS signed by the Governor, following consultation with the State’s Boards of Medicine and Nursing, requesting exemption from MD/DO supervision of CRNAs. The letter from the Governor must attest that he or she has consulted with State Boards of Medicine and Nursing about issues related to access to and the quality of anesthesia services in the State and has concluded that it is in the best interests of the State’s citizens to opt-out of the current MD/DO supervision requirement, and that the opt-out is consistent with State law. (2) The request for exemption and recognition of State laws, and the withdrawal of the request may be submitted at any time, and are effective upon submission. This Standard is not met as evidenced by: 47632 Based on observations made in the operating room with the lead anesthesia nurse (employee # 28) on 11/09/2025 at 8:49 AM, it was determined that the facility failed to ensure that the anesthesia service have quality meetings and indicators related to anesthesia. (Cross Refer Tag A0263) Findings include: During the interview with the lead anesthesia nurse (employee #28) stated she started at Anesthesia Professional Group in February 2025, she stated that they do not have a standards and procedures manual, quality meetings, anesthesia indicators, or staff education in the anesthesia area.”

“RESPIRATORY CARE SERVICES POLICIES CFR(s): 482.57(b) Services must be delivered in accordance with medical staff directives. This Standard is not met as evidenced by: 51782 Based on the review of policies, procedures and documents with the supervisor of the Respiratory Therapy Department (employee #6), it was determined that the facility failed to ensure that the organization of the respiratory care services is appropriate to the scope and complexity of the services. Findings included: 1.The Respiratory Therapy Department’s Policies and Procedures Manual was requested on 09/10/2025 at 10:47 AM. During the review, it was noted that it does not have a policy related to: a) Cardiopulmonary resuscitation procedures. b) The procedure to follow in the event of an adverse reaction to treatment or intervention.”

“RESPIRATORY CARE PERSONNEL POLICIES CFR(s): 482.57(b)(1) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing. This Standard is not met as evidenced by: 51782 Based on the review of documents with the Human Resources Manager (employee #30), it was determined that the facility failed to ensure the credentials files (CF) are updated qualification for respiratory therapy personnel. Findings include: 1. During review of six personnel credential files performed on 09/10/2025 from 2:30 PM through 3:30 PM provided evidence of the following: a) One out of six credential files were observed with cardiopulmonary resuscitation (CPR) certification expired on 09/2024 (C.F #5). b) One out of six respiratory therapy credential files failed to show updated evidence of in person Cardiopulmonary Resuscitation (CPR) accredited by the American Heart Association, the evidence provided was online CPR (C.F #1). c) One out of six credential files failed to show updated evidence of Influenza Vaccine or the Exoneration form for Influenza Vaccine (C.F #5). d) One out of six credential files failed to show updated evidence of evidence of the chickenpox vaccine or titers (C.F #6). e) One out six credential files were observed with Health certificated expired on 05/01/2025 (C.F #5). f) Four out of six credential files failed to show updated evidence of the annual evaluation (C.F. #1, #3, #4, #5). g) Five out of six credential files failed to show updated evidence of the competencies (C.F. #1, #2, #3, #4, #5). h) One out of six credential files failed to show updated evidence of evidence of the criminal record certificated (C.F #5).”

“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 09/11/2025 from 10:30 AM through 12:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide means to shelter in place for patients, staff and volunteers who remain in the facility. Findings include: During the review of the facilities Emergency Preparedness Program with the Physical Plant Supervisor (employee #34) on 09/11/2025 it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the Hospital during and after an emergency.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 09/11/2025 from 10:30 AM through 12:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the Physical Plant Supervisor (employee #34) on 09/11/2025 it was noted that the facility failed to stablished policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §482.15(b)(6).”

“Arrangement with Other Facilities CFR(s): §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 09/11/2025 from 10:30 AM through 12:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop arrangements with other facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. Findings include: During the review of the facilities Emergency Preparedness Program with Physical Plant Supervisor (employee #34) on 09/11/2025, it was noted that the EP failed to have written arrangements with other facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services. .”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 09/11/2025 at 10:30 AM through 12:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan. Findings include: During the review of the facilities Emergency Preparedness Program with the Physical Plant Supervisor (employee #34) on 09/11/2025, it was noted that the EP failed to develop and maintain an emergency preparedness training and testing program based on the facilities risk assessment.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 09/11/2025 from 10:30 AM through 12:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to maintain documentation of all emergency preparedness training. Findings include: During the review of the facilities Emergency Preparedness Program with the Physical Plant Supervisor (employee #34) on 09/11/2025, it was noted that the EP failed to provide documentation of training on emergency preparedness policies and procedures to all new and existing staff.”

“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 upon an Emergency Preparedness Program (EPP) survey performed on 09/11/2025 from 10:30 AM through 12:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to conduct exercises to test the emergency plan every two years. Findings include: During the review of the facilities Emergency Preparedness Program with the Physical Plant Supervisor (employee #34) on 09/11/2025, it was noted that the EP failed to conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise.”

“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 09/09/2025 at 10:00 am, 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 wich constituted an Immediate Jeopardy Findings include: On 9/9/2025 at 10:00 am a Puerto Rico Power Authoirty (LUMA) power outage occurs, alternative power (generator) was recovered 37 seconds after the event. During the 37 seconds that the facility was without power (neither from the power grid nor the generator) employees were observed holding cellular phone light to during procedures being performed in the surgical suites #1 and #6. Also complete hallways were observed with no emergency light functioning. Approximately at 1:41 PM the facility’s Project Manager request that the surveyor visit the the generators and the transfer switch area. The external company that provides service to the Hospital had completed the reprogramming process for both the three generators and the transfer switch. A test was conducted in the presence of the surveyor during which the facility was disconnected from the power grid and the generators started up in 8 seconds. Facility provided plan of correction at 2:52 PM A. TAG K918 Electrical Systems - Essential Electric System Maintenance and Testing B. Plan for correcting the deficiency 1) The Physical Plant Supervisor immediately contacted the power generator maintenance contractor (Today Smart Energy). 2) Technician updated the system programming and conducted tests in presence of surveyor LSC Lead Surveyor (See. Attachment 1). 3) During testing, generator start time was measured at three seconds. 4) During testing, the transfer load time was measured at eight (8) seconds. 5) The system was determined to be compliant with NFPA 110 standard. 6) The emergency light in the OR was replaced and observed to function properly. C. Plan for improving the process 1) The hospital has contracted the services of an independent firm to assist hospital personnel in conducting tests for maintaining compliance. 2) The system was determined to be compliant with NFPA 110 standard. E. Procedure for implementation 1) The physical plant has determined to update the testing schedule. 2) The hospital has contracted a firm to monitor compliance with transfer time. F. Tracking Procedure The hospital has contracted the services of an independent firm to assist hospital personnel in conducting tests for maintaining compliance. The maintenance schedule will include verification of transfer time metrics for assessment. G. Responsible Individuals 1) Department Supervisor 2) Physical Plant Director 3) Hosp. Administrator Surveyor accepted plan at 2:55PM.”

“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 Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to mantain free of all obstructions to full use in case of emergency. 18.2.1, 19.2.1, 7.1.10.1 Findings include: 1. Approximately at 8:37 AM on 09/10/2025 unattended trash can and vacum cleaner was observed obstructing exit discharge from Surgery Department exit. 2. Approximately at 10:35 AM on 09/10/2025 unattended regular trash can and equipment car were observed on both sides of corrridor reduceding exit access in hallway of the basemant next to exit. 3. Approximately at 11:40 AM on 09/10/2025 a folding table was observed in front of exit door next to the Pharmacy Department. The finding was verified by the Project Manager and Physical Plant Supervisor 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 inspect fire doors in the means of egress and maintain documentation in accordance with the requirements of NFPA 101, 2012 Edition, and NFPA 80, Fire Doors and Other Opening Protectives. Findings include: Approximately at 10:58 AM on 09/11/2025 evidence of fire doors inspections was requested and no written document was provided. The finding was verified by the Project Manager and Physical Plant Supervisor at the time of the observation.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for Life Safety from Fire of the Hospital with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to maintain Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 Findings include: 1. During a walk through the emergency stairs from the operating rooms to the outside, a section of these (fourth floor wall) was obseverd with penetrations from the staircase to the main buildig by metal rigid tubing that were not not protected by fire-resistant material. This can permit smoke, fire and noxious gases to enter the staircase in the event of a fire. The finding was verified by the Project Manager and Physical Plant Supervisor at the time of the observation.”

“Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for Life Safety from Fire of the Hospital with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed toprovide emergency illumination that would operate automatically along the means of egress and failed to have the required illuminance with two lamps energized during emergencies in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA 101 Sections 19.2.8, 7.8, 7.8.1.1, 7.8.1.2, 7.8.1.4 and 7.9.2.1 Findings include: 1. During a walk through the emergency stairs from the operating rooms to the outside, a section of these was observed that did not have regular lighting or emergency lighting. No proper ilumination on normal time and on an emergency can pose a threat of fall and confinement. The finding was verified by the Project Manager and Physical Plant Supervisor 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 Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to provide emergency illumination that would operate automatically along the means of egress and failed to have the required illuminance with two lamps energized during emergencies in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA 101 Sections 19.2.8, 7.8, 7.8.1.1, 7.8.1.2, 7.8.1.4 and 7.9.2.1. Findings include: 1. No emergency lighting on waitoing area of Emergency Ward. 2. No emergency lighting on emergency stairways (North and South). 3. No emergency lighting on inside the outside of exit discharge. 4. No emergency lighting in the CT Room. 5. No emergency lighting in the Fire Pump Area 6. On 9/9/2025 at 10:00 am a Puerto Rico Power Authoirty (LUMA) power outage occurs, alternative power (generator) was recovered 37 seconds after the event. During this time complete hallways on the Surgery Department were observed with no emergency light functioning. The finding was verified by the Project Manager and Physical Plant Supervisor 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 Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to ensure exit and directional exit signs were provided and means of egress marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants in accordance with NFPA 101, 2012 Edition, Section 19.2.10.1 and 7.10. Findings include: 1. Observation and interview on 09/09/2025 at approximately 9:05 AM on the Surgery Department it was noticed that exit sign provided in the area could case confusion beacise of location and should be relocated to front of exit door. 2. Observation and interview on 09/09/2025 at approximately 10:10 AM, no exit sign was observed in either (2) exits of the Recovery Ward on the Surgery Department. 3. Observation and interview on 09/010/2025 at approximately 10:05 AM, no exit sign was observed on “Fase 2” area. 4. Observation and interview on 09/10/2025 at approximately 11:05 AM, no exit sign was observed on the emergency exit hallway next to the boiler rooms. 5. Observation and interview on 09/11/2025 at approximately 9:35 AM, exit sign on the Laboratory area was found with directional chevron signaling to the bathroom area (left), not to the proper direction to exit discharge. It should be signaling to the right. 6. Observation and interview on 09/11/2025 at approximately 10:05 AM, no exit sign was observed on the emergency exit (basement) of South side emergency stairway. The finding was verified by the Project Manager and Physical Plant Supervisor at the time of the observation.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for Life Safety from Fire of the Hospital with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to maintain Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 Findings include: 1. Approximately at 12:05 PM on 09/11/2025, penetrations were observed on the boilers room on the basement. Multiple penetrations were observed by PVC pipiping and rigid metal piping wiyh no fire profing material, in the event of a fire in this area smoke, fire and noxious gases to enter other areas of the facility. The finding was verified by the Project Manager and Physical Plant Supervisor at the time of the observation.”

“Anesthetizing Locations CFR(s): NFPA 101 Anesthetizing Locations Areas designated for administration of general anesthesia (i.e., inhalation anesthetics) are in accordance with 8.7 and NFPA 99. Zone valves are: located immediately outside each life-support, critical care and anesthetizing location of moderate sedation, deep sedation, or general anesthesia for medical gas or vacuum; readily accessible in an emergency; and arranged so shutting off any one anesthetizing location will not affect others. Area alarm panels are provided to monitor all medical gas, medical-surgical vacuum, and piped WAGD systems. Panels are at locations that provide for surveillance, indicate medical gas pressure decreases of 20 percent and vacuum decreases of 12 inch gauge HgV, and provide visual and audible indication. Alarm sensors are installed either on the source side of individual room zone valve box assemblies or on the patient/use side of each of the individual zone box valve assemblies. The EES critical branch supplies power for task illumination, fixed equipment, select receptacles, and select power circuits, and EES equipment system supplies power to ventilation system. Heating, cooling, and ventilation are in accordance with ASHRAE 170. Medical supply and equipment manufacturer’s instructions for use are considered before reducing humidity levels to those allowed by ASHRAE, per S&C 13-58. 19.3.2.3 (LSC) 5.1.4.8.7, 5.1.4.8.7.2, 5.1.9.3, 5.1.9.3.4, 6.4.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for Life Safety from Fire of the Hospital with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to provide that Zone valves are located immediately outside each life-support, critical care and anesthetizing location of moderate sedation, deep sedation, or general anesthesia for medical gas or vacuum; readily accessible in an emergency; and arranged so shutting off any one anesthetizing location will not affect others. Findings include: Approximately at 9:58 AM on 09/09/2025 , in the Surgery Department, six (6) shut off valves were observed in the hallway leading to two (2) Operating Rooms (OR) “Sala 2 and Sala 3”, those six valves were not labeled as per which correponded to those two (2) OR. No zone valve was located immediately outside of either of the OR. The finding was verified by the Project Manager and Physical Plant Supervisor at the time of the observation.”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 47384 Based on observation and interview, the facility failed to visually inspect and maintain fire suppression manual release and fire suppression system in accordance with the requirements NFPA 101, 2012 Edition, Section 18.3.2.5.1 through 18.3.2.5.4 and 9.2.3 and NFPA 96, 2011 Edition. Findings include: 1. Observation on September 10, 2025 at approximately 10:45 AM Kitchen revealed that the ANSUL manual release inspection tag and releasing mechanism inspection tag lacked monthly inspection (date and initials) of the ANSUL system in accordance with the manufacturer’s maintenance manual was that requires it is completed at a minimum of 30-day intervals. 2. Nozzles on the fire supression system were missing blow-off caps. Five (5) unprotected nozzles were observed. The finding was verified by the Project Manager and Physical Plant Supervisor at the time of the observation.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for Life Safety from Fire of the Hospital with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed toit was determined that the facility failed to maintain initiation devices in all areas. Findings include: 1. On 09/09/2025, approximately at 8:45 AM, in the Surgery Department , no smoke detector was found in Operation Room #8. 2. On 09/09/2025, approximately at 8:45 AM, in the Surgery Department , no smoke detector was found in Operation Room #9. 3. On 09/09/2025, approximately at 9:30 AM, in the Surgery Department , no smoke detector was found in UPC room. 4. On 09/09/2025, approximately at 10:30 AM, in the Surgery Department , no smoke detector was found in Operation Room #5. 5. On 09/10/2025, approximately at 9:00 AM, in the Emergency Ward , no smoke detectors were found in Isolation Rooms #8 and #9. 6. On 09/10/2025, approximately at 9:00 AM, in the Intensive Care Ward , no smoke detectors were found in Isolation Rooms #1 and #2. 7. On 09/10/2025, approximately at 9:20 AM, in the Intensive Care Ward , manual activation device (pull station) was observed by drawers. 8. On 09/10/2025, approximately at 1:00 PM, in the Radiology Care Ward , no smoke detectors were found in the CT room. 9. On 09/10/2025, approximately at 2:30 PM, in the third floor, no smoke detectors were found in the dialysis treatment room. The finding was verified by the Project Manager and Physical Plant Supervisor at the time of the observation.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 47384 Based on observation, interview, the facility failed to ensure all devices associated with the fire alarm system were tested annually, maintain complete and accurate documentation, manufacturer’s acceptable sensitivity range and testing of the fire alarm system in accordance with the requirements of NFPA 70 2011 Edition and NFPA 72 2010 Edition, NFPA 101, 2012 LSC Edition, Section 9.7.5, 9.7.7, 9.7.8 and NFPA 25 2011 Edition. Findings include: 1. Fire alarm annunciator reported 3 troubles signals that were not restored to normal within 200 seconds. a) MED. BLDG OFFICE 202 CUBICULO 6 MAY 1 SMOKE service required b) MED. BLDG 2FL UTILITY/STORAGE APR 27 SMOKE service required c) 1FL MEDIC RECORDS APR 27 SMOKE service required 2. Fire alarm annunciator reported 1 supervisory signal that was not restored at the time of the Survey. a) FIRE PUMP SYSTEM FAIL APR 27 No Interim Life Safety Measure was presented at the time of the survey. The finding was verified by the Project Manager and Physical Plant Supervisor at the time of the observation.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(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 Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to protect facility throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. Findings include: 1. No sprinklers were observed on the first accessible landing on the north stair. 2. No sprinklers were observed on the first accessible landing on the south stairs. The finding was verified by the Project Manager and Physical Plant Supervisor at the time of the observation.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for Life Safety from Fire of the Hospital with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed toit was determined that the facility failed to maintain the system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection. Findings include: 1. Observation and interview on 09/09/2025 at approximately 8:30 AM, on Surgery Department, it was observed that scutcheons plate were missing on sprinklers of Operation rooms #2 and #3. 2. Observation and interview on 09/09/2025 at approximately 1:30 PM, on Waiting area of Emergency Ward, 1 out of 4 lids of concealed sprinklers was missing. 3. Observation and interview on 09/09/2025 at approximately 1:30 PM, on Registry area of Emergency Ward, 1 out of 2 lids of concealed sprinklers was missing. 4. Observation and interview on 09/09/2025 at approximately 1:40 PM, on Trauma area of Emergency Ward, 2 out of 2 lids of concealed sprinklers were missing. 5. Observation and interview on 09/09/2025 at approximately 1:45 PM, in front of Trauma area of Emergency Ward, 2 sprinklers were obseverd with red plastic protective cover used for instalation. 6. Observation and interview on 09/09/2025 at approximately 2:00 PM,in the outside of Emergency Ward, Siamese Connection was observed obstructed by a Trash Can. 7. Observation and interview on 09/10/2025 at approximately 8:30 AM, on the lounge of Intensive Care Ward, 1 lid of concealed sprinklers was missing. 8. Observation and interview on 09/10/2025 at approximately 9:30 AM, on the Isolation room #1 of Intensive Care Ward, 1 out of 2 lids of concealed sprinklers was missing. 9. Observation and interview on 09/10/2025 at approximately 9:30 AM, on the Isolation room #2 of Intensive Care Ward, 1 out of 2 lids of concealed sprinklers was missing. 10. Observation and interview on 09/10/2025 at approximately 9:30 AM, on the Cubicule #6 of Intensive Care Ward, 2 out of 2 lids of concealed sprinklers was missing. 11. Observation and interview on 09/10/2025 at approximately 1:10 PM, on Fast Track area of Emergency Ward, 2 out of 4 lids of concealed sprinklers were missing. 12. Observation and interview on 09/10/2025 at approximately 1:30 PM, on the Laboratory Ward, 3 out of 3 lids of concealed sprinklers were missing. 13. Based on observation and record review there was no documentation provided regarding the sprinkler piping internal inspection, pressure gauges on the sprinkler main were replaced or tested by comparison with a calibrated gage within the last five years The finding was verified by the Project Manager and Physical Plant Supervisor 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 Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), 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 09/09/2025 approximately at 9:00 AM a type ABC fire extinguisher was observed blocked by printer in the nurses counter of the Recovery Ward in the Surgery Department. 2. On 09/10/2025 approximately at 10:45 AM a type K fire extinguisher was observed blocked by a transport cart on the kitchen. 3. On 09/10/2025 approximately at 11:00 AM a type ABC fire extinguisher was observed blocked by a trash can on the General warehouse. 4. During observation of all areas of the Hospital, it was observed that the fire extinguisher cabinets did not permit easy acces to the extinguisher. The acrylic cover should have a handle for easy removal. 5. During observation of all areas of the Hospital, it was observed that the fire extinguisher cabinets exeeded the five foot mounting height for extinguishers on 40 lbs or less. The finding was verified by the Project Manager and Physical Plant Supervisor 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 Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to have patient’s sleeping room doors tested, it was found that patient’s sleeping rooms do not latch when the doors are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request. Findings include: 1. Third floor: #302, #305, #306, #310, #311, #313, #314, #315, #316, #317, #318, #319, #321 2. Fourth floor: #413, #415, #416, #417, #418, #419, #420, #421, #422 The finding was verified by the Project Manager and Physical Plant Supervisor at the time of the observation.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 47384 Based on document review and interviews conducted during the survey for life safety from fire of the Hospital with the facility’s the Safety Officer (employee #2) and Engineering Director (employee #13), it was determined that the facility failed to perform quarterly Fire Drills as required on 19.7.1.4 through 19.7.1.7. Findings include: During document review of fire drills, it was observed that facility did not comply with the required drills in each of the shifts for all quarters.”

“Draperies, Curtains, and Loosely Hanging Fabr CFR(s): NFPA 101 Draperies, Curtains, and Loosely Hanging Fabrics Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall. 18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for Life Safety from Fire of the Hospital with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to certify that dividing curtains are up to standard with NFPA 701 in accordance with 10.3.1. Findings include: During observational tour on faclity’s Surgery Department, Intensive Care, CT as well as the Emergency Ward. No tag with flame retardant or fire resistant in accordance with an equivalent standard to NFPA 701 was observed on curtains.”

“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 and interviews made during the survey for Life Safety from Fire of the Hospital with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to inspect fire doors in the means of egress and maintain documentation in accordance with the requirements of NFPA 101, 2012 Edition, and NFPA 80, Fire Doors and Other Opening Protectives. Findings include: Approximately at 10:58 AM on 09/11/2025 evidence of fire doors inspections was requested and no written document was provided. The finding was verified by the Project Manager and Physical Plant Supervisor at the time of the observation.”

“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 Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to maintain areas free of portable space heating devices. 18.7.8, 19.7.8 Findings include: Two (2) portable heaters were obseverd on the Information Management Department.”

“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 interviews made during the survey for Life Safety from Fire of the Hospital with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), 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 Shutoff valves was observed throughout the facility. 2. Medical Gas Alarm panels were observed unoperational on the Surgery Department. The finding was verified by the Project Manager and Physical Plant Supervisor at the time of the observation”

“Gas and Vacuum Piped Systems - Maintenance Pr CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Maintenance Program Medical gas, vacuum, WAGD, or support gas systems have documented maintenance programs. The program includes an inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets. Inspection and maintenance schedules are established through risk assessment considering manufacturer recommendations. Inspection procedures and testing methods are established through risk assessment. Persons maintaining systems are qualified as demonstrated by training and certification or credentialing to the requirements of AASE 6030 or 6040. 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (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 Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to include a inventory of all source systems, control valves, alarms, manufactured assemblies, and outlets inspected. Findings include: 1. Approximately at 9:30 AM on 09/09/2025 a medical gases shutoff valve was observed with the protective acrylic cover screwed to the box. 2. Approximately at 11:30 AM on 09/11/2025 evidence of medical gases inspections was requested, according to the review of the evidence provided, no breakdown of the devices inspected by the external company could be found.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for Life Safety from Fire of the Hospital with the facility’s Project Manager (Employee #33) and the Physical Plant Supervisor (employee #34), it was determined that the facility failed to maintain the generator or other alternate power source and associated equipment to supply service within 10 seconds, which resulted on an Immediate Jeopardy. Findings include: On 9/9/2025 at 10:00 am a Puerto Rico Power Authoirty (LUMA) power outage occurs, alternative power (generator) was recovered 37 seconds after the event. During the 37 seconds that the facility was without power (neither from the power grid nor the generator) employees were observed holding cellular phone light to during procedures being performed in the surgical suites #1 and #6. Also complete hallways were observed with no emergency light functioning. Approximately at 1:41 PM the facility’s Project Manager request that the surveyor visit the the generators and the transfer switch area. The external company that provides service to the Hospital had completed the reprogramming process for both the three generators and the transfer switch. A test was conducted in the presence of the surveyor during which the facility was disconnected from the power grid and the generators started up in 8 seconds. Facility provided plan of correction at 2:52 PM A. TAG K918 Electrical Systems - Essential Electric System Maintenance and Testing B. Plan for correcting the deficiency 1) The Physical Plant Supervisor immediately contacted the power generator maintenance contractor (Today Smart Energy). 2) Technician updated the system programming and conducted tests in presence of surveyor LSC Lead Surveyor (See. Attachment 1). 3) During testing, generator start time was measured at three seconds. 4) During testing, the transfer load time was measured at eight (8) seconds. 5) The system was determined to be compliant with NFPA 110 standard. 6) The emergency light in the OR was replaced and observed to function properly. C. Plan for improving the process 1) The hospital has contracted the services of an independent firm to assist hospital personnel in conducting tests for maintaining compliance. 2) The system was determined to be compliant with NFPA 110 standard. E. Procedure for implementation 1) The physical plant has determined to update the testing schedule. 2) The hospital has contracted a firm to monitor compliance with transfer time. F. Tracking Procedure The hospital has contracted the services of an independent firm to assist hospital personnel in conducting tests for maintaining compliance. The maintenance schedule will include verification of transfer time metrics for assessment. G. Responsible Individuals 1) Department Supervisor 2) Physical Plant Director 3) Hosp. Administrator Surveyor accepted plan at 2:55PM.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 15884 Based on the Emergency Medical Treatment and Labor Act EMTALA complaint investigation (PR00000683), review of twenty closed records and five active records reviewed (R.R), policies/procedures manual, review of medical faculty by laws rules and regulations and documents related to complaint case, it was determined that the hospital failed to provide sufficient oncall specialty services to meet the needs of their community cosistent with the services provided at the hospital.”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 15884 Based on interview and record review, the hospital failed to provide sufficient oncall specialty services to the meet the needs of their community consistent with the services provided at the hospital. Findings include: Review on 03/05/24 at 9:30 AM of the facility’s policy title Stabilizing Services in the Emergency Room, Procedure in cases requiring specialized services in the emergency room last update on 07/01/23. Policy stated on the procedures that in cases where a necessary specialized service is unavailable at the specific time, the physician will coordinate a patient transfer to a nearby facility offering said services and certify the necessary risk-benefit analysis has been performed. 1. During interview on 03/06/24 at 10:00 AM it was asked to the facility chief executive officer (employee #1) if facility had on-call physicians who are on the medical staff or who had privileges at the hospital available to provide surgery services and treatment necessary after initial examination to stabilize individuals with emergency medical conditions. 2. Chief executive officer (employee #1) explained in an interview on 03/06/24 at 10:10 AM that the facility did not have surgery on-call services at the emergency room. He stated that the facility had written policies and procedures in place to respond to situations in which a particular specialty is not available. He stated the facility only had 2 surgeons who were on the medical staff that had privileges at the hospital available to surgery services, but those two surgeons did not take turns to perform on call services at the emergency room. He stated that there are not monthly on call roster surgery specialty because the two surgeons who provide services at the facility did not take turns or are assigned to perform on call services at the emergency room since more than a year ago. 3.Chief executive officer (employee #1) stated on interview on 03/06/24 at 10:30 AM that the facility policy in place establish that when a specialty is not available, patients who need treatment of this specialty if received on the emergency room are screened, stabilized, and transferred to other facility who had the specialty. 4. Chief executive officer (employee #1) stated in an interview on 03/06/24 at 10:35 AM that that the hospital does not have a general on call program with surgeons. Our hospital has 2 general surgeons that form part of our medical faculty but none of them perform emergency room general surgeon on call services. Both provide surgery services to admitted patients that comes referral from physicians’ offices and to other hospital admitted patients when physicians from other specialties refer patients to them. Those 2 general surgeons provide surgery services to patients consulted from emergency room and in certain circumstances perform surgery procedures to those patients but not on a regular basis. Surgery on call services is not available in the emergency room. 5. The hospital failed to maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services or are in need of surgery. 6. The following are example of patients who visit facility and based of their chief complaint need further evaluation and treatment that need to be provided by surgery specialty and was not provided due to lack of availability of surgery services on the emergency room: a. RR #4 is a 62-year-old female, who visited the Emergency Room on 10/02/2023. The patient was diagnosed with appendicitis and requiring a surgical procedure. This case was evaluated and transferred to another facility for surgery on 12/03/2023. Once the case went to the other hospital them refused to allow the patient into the facility and she was sent back. Patient was received at the emergency room and admitted to inpatient services on 12/03/2023. The hospital had the capability to perform the surgery as evidenced by the surgery was performed on 12/04/2023 at 12:50 PM. b. RR #7 is a 76-year-old female, who visited the Emergency Room on 11/07/2023. The patient was diagnosed with Bleeding Post surgical wound. This patient was evaluated and transferred to another facility for further evaluation and treatment.”