Hospital Perea

“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: 51782 Based on the review of personnel credential files (C.F) during survey performed 12/16/2025 through 12/19/2025 from 9:00 AM till 4:00 PM it was determined that the facility failed to ensure that professional staff complies with federal, state, and local laws to keep current personnel qualifications. This deficient practice was identified in 7 out of 8 personnel credential files reviewed. Findings include: 1. During review of eight personnel nurse credential files (N.C.F), with the Human Resources Supervisor (employee #3) performed on 12/19/2025 at 1:35 PM till 2:15 PM provided evidence of the following: a) Two out of eight (N.C.F) failed to show updated evidence of the CPR, (N.C.F #1 and #3). b) Seven out of eight (N.C.F), failed to show updated evidence of influenza vaccine or the exoneration form for influenza vaccine, (N.C.F #1, #2, #3, #4, #5, #6 and #8). 2. During review of four credential files (C.F) of staff Imaging Center Department with Human Resources Coordinator (employee # 41), performed on 12/19/2025 from 3:00 PM to 3:15 PM, the following was found: a) Two out of four credential files failed to show updated evidence of Influenza vaccine or the exoneration form for Influenza Vaccine, (C.F #1, and #2). b) One out of four credential files failed to show evidence of annual evaluation (C.F #1). c) One out of four 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 #3) provides evidence of an online CPR expiration on 07/17/2027.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 51629 Based on interviews with the hospital Admission Department Supervisor (employee # 8) and record review performed from 12/17/2025 at 9:30 AM and 12/18/2025 at 11:00 AM, it was determined that the facility failed to implement and maintain a procedure for the notification and delivery of the patient’s Notice of Rights. This deficient practice was identified in 4 out of 8 open and closed records reviewed (RR # 7, # 8, # 9 and # 12). Findings include: 1. During an interview with the Admission Department Supervisor (employee # 8) on 12/18/2025 at 1:30 PM, she stated that during the admission procedure, the documents to be provided to patients and relatives contain the notice of rights. 2. An open and closed record review was done on 12/17/2025 at 9:30 AM and 12/18/2025 at 11:00 AM. a. RR # 7 is a 76-year-old female who was admitted on 11/29/2025 with a diagnosis of Bronchopneumonia. During record review performed on 12/17/2025, the clinical record did not contain a delivery and orientation certification, as evidence that a copy of the Notice of Rights was provided to the patient or patient’s representative. b. RR # 8 is a 98-year-old female who was admitted on 11/30/2025 with a diagnosis of Bronchitis. During record review performed on 12/17/2025, the clinical record did not contain a delivery and orientation certification, as evidence that a copy of the Notice of Rights was provided to the patient or patient’s representative. c. RR # 9 is a 93-year-old female who was admitted on 12/04/2025 with a diagnosis of Congestive Heart Failure. During record review performed on 12/17/2025, the clinical record did not contain a delivery and orientation certification, as evidence that a copy of the Notice of Rights was provided to the patient or patient’s representative. a. RR # 12 is a 25-year-old female who was admitted on 12/16/2025 with a diagnosis of 39 weeks gestation. During record review performed on 12/18/2025, the clinical record did not contain a delivery and orientation certification, as evidence that a copy of the Notice of Rights was provided to the patient or patient’s representative. The facility did not maintain and demonstrate evidence that, during the admission process, the procedure for the notification and delivery of the patient’s Notice of Rights is clearly explained to patients or representatives.”

“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 # 2), document review and five record reviewed (RR) performed on 12/17/2025 at 11:10 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 # 5, # 6, # 7, # 8 and # 9). Findings include: During an interview with Social Worker (employee # 2) on 09/11/2025 at 11:00 AM, she stated that in each intervention the discharge program staff orients the patients about their rights. 1.RR # 5 is an 87-year-old male Medicare beneficiary who was admitted on 12/08/2025 with a diagnosis of Atrioventricular Block, 2nd degree. The patient was discharged home. The clinical record evidences a copy of the Medicare Important Message signed by the patient but not dated (date and hour). 2.RR # 6 is a 82-year-old male Medicare beneficiary who was admitted on 12/09/2025 with a diagnosis of Cholelithiasis. The patient was discharged home. The clinical record evidences a copy of the Medicare Important Message signed by the patient but not dated (date and hour). 3. RR # 7 is a 76-year-old female Medicare beneficiary who was admitted on 11/29/2025 with a diagnosis of Bronchopneumonia. The patient was discharged home on 12/04/2025. The clinical record evidences a copy of the Medicare Important Message signed by the patient but not dated (date and hour). 4. RR # 8 is a 98-year-old female Medicare beneficiary who was admitted on 11/30/2025 with a diagnosis of Bronchitis. The patient was discharged home on 12/04/2025. The clinical record evidences a copy of the Medicare Important Message signed by the patient but not dated (date and hour). 5. RR # 9 is a 93-year-old female Medicare beneficiary who was admitted on 12/04/2025 with a diagnosis of Congestive Heart Failure. The patient was discharged home on 12/15/2025. The clinical record evidence a copy of the Medicare Important Message signed by the patient but not dated (date and hour). The facility failed to inform each patient of their rights, in advance of discontinuing patient 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 Intensive Care Unit Supervisor (employee # 7), records reviewed performed on 12/17/2025 at 9:30 AM and document review performed on 12/19/2025 at 1:40 PM, it was determined that the facility failed to implement and maintain a procedure for the staff and practitioners who provide care in the hospital to comply with the advance directives. This deficient practice was identified in 1 out of 1 open record reviewed (RR # 10). Findings include: 1.During an interview with the Intensive Care Unit Supervisor (employee # 7), record review performed on 12/17/2025 at 9:30 AM, she stated that in each nursing shift, the registered nurse (RN) should document the current status of the patient in a Do Not Resuscitate Protocol (DNR). 2.The policy named “Protocolo No Resucitar (DNR)- Do not Resucitate o No Entubar (DNI)-Do not Intubate (02/2024 revision) was reviewed on 12/19/2025 at 1:40 PM. The facility policy states that the physician will document in the progress notes the reasons for arriving at the determination of DNR or DNI in agreement with the patient and/or family. 3.RR # 10 is a 97-year-old male who was admitted on 11/24/2025 at 1:05 PM with a diagnosis of Sepsis and Pleural Effusion. a.On 11/24/2025 the primary physician ordered DNR protocol, but it is not mentioned in the progress note; nor is the determination made in agreement with the family. b.During the patient’s stay in the Medicine III unit, the nursing progress notes for 6 work shifts (11/25/2025 - 11/26/2025) were evaluated ; none of these indicate that the patient is on DNR protocol. c.The patient was transferred to the Intensive Care Unit on 12/7/2025 at 5:30 PM. The nursing progress notes for 7 work shifts (11-7 shift of 12/7/2025 through 12/9/2025) were ealuated; except for the 11-7 shift on 12/9/2025 none of these indicate that the patient was on DNR protocol. The facility did not maintain and demonstrate evidence that hospital staff and practitioners who provide care to patients with advanced directives comply with these directives.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 47632 Based on observations made in the operating room with the operating room supervisor (employee #15) on 12/17/2025, it was determined that the facility failed to ensure that the patient received a safe and supervised environment. Findings include: On 12/17/2025 at 11:14 AM, patient roster (P.R.) #19, a 78-year-old male admitted on 12/02/2025 with a Percutaneous Endoscopic Gastrostomy (PEG) tube placement, located in the pre-anesthesia entrance with non-invasive ventilatory support (Bipap), without an escort, without nursing staff, and without respiratory therapy present. The patient did not have continuous monitoring or clinical supervision, which represents an unsafe environment and a risk to patient safety.”

“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 records reviewed (RR) interviews with the hospital Admission Department Supervisor (employee # 8) and document review performed on 12/16/2025 at 3:00 PM, it was determined that the facility failed to implement and maintain a procedure for the notification and delivery of the patient’s right to be free from all forms of abuse, neglect and harassment. This deficient practice was identified in 10 out of 10 records reviewed (RR. # 5, # 6, #7, # 8, # 9, # 10, # 12, # 13, # 38, and # 39). Findings include: 1. During an interview with the Admission Department Supervisor (employee # 8) on 12/18/2025 at 1:30 PM, she stated that during the admission procedure, the documents to be provided to patient and relative contain the notice of rights. 2. During document review performed on 12/16/2025 at 3:00 PM, it was identified that the hospital notice of rights does not include the patient’s right to be free from all forms of abuse, neglect and harassment. The Facility failed to maintain and demonstrate evidence that, during the admission process, the procedure for the notification and delivery of the patient’s notice of rights (including the patient’s right to be free from all forms of abuse, neglect and harassment) is clearly explained to patients or representatives.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 51629 Based on interviews with the hospital Admission Department Supervisor (employee # 8) and document review performed on 12/16/2025 at 3:00 PM, it was determined that the facility failed to inform the patient and his representative about the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. This deficient practice was identified in 10 out of 10 cases reviewed (RR # 5, RR # 6, RR #7, RR # 8, RR # 9, RR # 10, RR # 12, RR # 13, RR # 38, RR # 39). Findings include: 1. The document named: “Guía Informativa del Paiente”, as part of the admission documents, was discussed and reviewed with the Admission Department Supervisor (employee # 8) on 12/16/2025 at 3:00 PM. a. The facility document does not include the right of the patient to be free from all forms of restraint or seclusion. The facility failed to demonstrate that the patient and representative will be informed (during the admission process) about their right to be free from all forms of restraint or seclusion.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 51629 Based on interviews with the Director of Nursing DON (employee # 11) performed on 12/19/2025 at 1:40 PM, documents reviewed, and records reviewed (RR) performed on 12/19/2025 at 11:30 AM, it was determined that the facility failed to evidence that the use of restraint or seclusion is in accordance with a written modification to the patient’s plan of care. This deficient practice was identified in 2 out of 2 records reviewed (RR # 38 and RR # 39). Findings include: 1. During an interview with Director of Nursing DON (employee # 11) performed on 12/19/2025 at 1:40 PM, she states that, according to facility policy and procedure, documentation of a plan of care and reassessments are part of the documentation requirements. 2. The facility’s policy named: “Protocolo de Restricciones de Pacientes” Patient Restrictions Protocol (10/2024 revision) was reviewed on 12/19/2025 at 1:40 PM. The facility policy states that nursing personnel are responsible for the activation of a plan of care. The physician in charge is responsible for documenting in the progress note, the start and justification for continuing or discontinuing the restriction. 3. RR # 38 is a 91-year-old female who was admitted on 10/25/2025 with a diagnosis of Congestive Heart Failure Exacerbation. After the admission and while the patient was in the emergency room, the physician prescribed (on 10/26/2025 at 1:00 AM) an order to restrain the upper extremities. The order was executed by the registered nurse (RN) but there is no evidence of a documented plan of care. 4. RR # 39 is a 74-year-old male who was admitted on 10/11/2025 at 3:00 PM with a diagnosis of Cholecystitis and Right Leg Cellulitis. On 10/17/2025 at 8:00 PM, the physician prescribed an order to restrain the upper extremities. The physician documented a progress note on 10/17/2025 at 9:00 PM but did not mention the restraint event; neither justification for starting it nor plan to continue. The facility failed to evidence that the use of restraint or seclusion is in accordance with a written modification to the patient’s plan of care.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 51629 Based on interviews with the Director of Nursing DON (employee # 11) performed on 12/19/2025 at 1:40 PM, document review and records reviewed (RR), performed on 12/19/2025 at 11:30 AM, it was determined that the facility failed to evidence that the condition of the patient who is restrained or secluded is monitored at an interval determined by hospital policy. This deficient practice was identified in 1 out of 2 records reviewed (RR # 38). Findings include: 1. During an interview with Director of Nursing DON (employee # 11) performed on 12/19/2025 at 1:40 PM, she states that, according to facility policy and procedure, documentation of reassessments is part of the documentation requirements. 2. The facility policy named: “Protocolo de Restricciones de Pacientes” Patient Restrain Protocol (10/2024 revision) was reviewed on 12/19/2025 at 1:40 PM. The facility policy states that nursing personnel are responsible for the reassessments every 30 minutes, 1 hour or 2 hours according to patient’s age. a. RR # 38 is a 91-year-old female who was admitted on 10/25/2025 with a diagnosis of Congestive Heart Failure Exacerbation. After the admission and while the patient was in the emergency room, the physician prescribed (on 10/26/2025 at 1:00 AM) an order to restrain the upper extremities and reassessments every two hours. The order was executed by the registered nurse (RN) but there is no evidence of reassessments every two hours, with the exception of two entries in the clinical record as follows: 10/26/2025 at 12:00 PM and 10/26/2025 at 5:30 PM. The patient was transferred to the intensive care unit (ICU) on 10/27/2025 at 8:30 AM, without restraints. The record does not show when the restraints were discontinued by the RN in the emergency room. The facility failed to evidence that the monitoring is in accordance with hospital policy.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 47632 Based on interviews conducted with the operating room manager (employee #15), anesthesia supervisor (employee #19), and catheterization supervisor (employee #14) from 12/16/2025, to 12/19/2025, it was determined that the facility failed to ensure the integration of infection control indicators into quality indicators. Findings include: 1. During the interview with the catheterization supervisor (employee #14) on 12/17/2025 at 10:40 AM, she stated that infection control was not included in her quality indicators. 2. During the interview with the anesthesia supervisor (employee #19) on 12/19/2025 at 1:30 PM, he stated that infection control was not included in her quality indicators. 3. During the interview with the operating room supervisor (employee #15) on 12/11/2025 at 11:19 AM, she stated that infection control was not included in her quality indicators. The facility failed to include infection control into the quality indicators.”

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 51629 Based on interviews with the Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and documents reviewed performed on 12/19/2025 at 9:00 AM, it was determined that the facility failed to develop, implement and maintain performance improvement activities to track medical errors, adverse events, verbal / telephone orders and medication use through an effective, ongoing, data-driven quality assessment and performance improvement program for pharmacy services. Findings include: 1. During interview with the Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and document review performed on 12/19/2025 at 9:00 AM, she stated that the facility has a pharmacy and therapeutic committee, but no policy and procedure was provided to review its members, meetings frequency and performance improvement activities to discuss and monitor. a.The committee record file shows one minute (03/25/2025). During document review, it was found that the only topic discussed was the acquisition of a parenteral nutrition product. Instead of that, the director of pharmacy (employee # 20) stated that she held individual meetings with the leaders associated with medication use. b.The antibiotic stewardship program has not held any meetings since 04/01/2022. Instead of that, the director of pharmacy (employee # 20) stated that she held individual meetings with the leaders associated with antibiotic use. The facility did not maintain and demonstrate evidence of its performance improvement activities to track medication use thorough the hospital.”

“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 Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and documents reviewed performed on 12/19/2025 at 9:00 AM, it was determined that the facility failed to develop, implement and maintain an effective, ongoing, data-driven quality assessment and performance improvement program (QAPI) for pharmacy services. Findings include: 1. During interview with the Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and document review performed on 12/19/2025 at 9:00 AM, she stated that they maintain statistics and tables with the record of all medication errors (prescription, dispatch and administration) and adverse drug reactions but did not provide quality indicators on aspects to be monitored. 2. During interview with the Director of Pharmacy Services (employee # 20) and document review, no information was provided about performance improvement projects. 3. The facility did not maintain and demonstrate evidence of its QAPI program for the pharmacy services and performance improvements projects that reflects its scope, complexity and operations.”

“MEDICAL STAFF CREDENTIALING CFR(s): 482.22(a)(2) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidates in accordance with State law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section. This Standard is not met as evidenced by: 51829 Based on review of nine Medical Staff Credential Files (MSFs) on December 19, 2025, at 1:30 p.m., and interviewing the Medical Staff Coordinator (Employee #42), it was determined that the hospital did not ensure the periodic re-evaluation of vaccinations against hepatitis, influenza, and COVID-19. The deficient practice was identified on 8 out of 9 MSF (MSF #2,#3, #4, #5, #6, #7, #8 and #9). Findings include: 1. During a review of the credential files of nine medical professionals, conducted on December 19, 2025, at 1:30 p.m., no evidence of vaccination was identified for any of them. These credentials are for required vaccinations: a. There is no evidence of vaccination and/or titers for the hepatitis vaccine for employees #6, #7, #8, and #9. b. There is no evidence or documentation of annual refusal of the influenza vaccine for employees #2, #3, #4, #5, #8, and #9. c. There is no evidence and/or legal documentation regarding the administration of the COVID-19 vaccine to employees #8 and #9. 2. According to the Internal Regulations of the Facility in Mayagüez, professional credentials are required to maintain their privileges. However, their medical privileges at the hospital were marked as up to date.”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 47632 Based on review of the anesthesia standards and procedures manual on 12/18/2025 at 1:30 PM, it was determined that the facility failed to ensure that the anesthesia flowchart was up to date. Findings include: During the interview with the anesthesia supervisor (employee #19), it was observed that the organizational chart was not up to date in terms of positions and supervision in effect since 06/2016.”

“PHARMACIST SUPERVISION OF SERVICES CFR(s): 482.25(b)(1) §482.25(b)(1) - All compounding, packaging, and dispensing of drugs and biologicals must be under the supervision of a pharmacist and performed consistent with State and Federal laws. This Standard is not met as evidenced by: 51629 Based on interviews with the Director of Pharmacy Services (employee # 20) performed on 12/19/2025 at 9:00 AM, Director of Nursing (employee # 1) and other nursing leaders performed during survey, documents reviewed performed on 12/19/2025 at 9:00 AM and rounds thorough the clinical areas performed, it was determined that the facility failed to demonstrate that all compounding, packaging, and dispensing of drugs and biologicals are done under the supervision of a pharmacist and performed consistent with Federal and State law. Findings include: 1. During the interview with the Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and document review performed on 12/19/2025 at 9:00 AM, she stated that the pharmacy department does not have an IV room. All the medications that need to be reconstituted, mixed, and those considered compounded preparations are dispatched to the clinical units to be prepared by the nursing staff. No pharmacy staff supervise the process of medication reconstitution and mixing performed by nursing staff before it is administered. 2. During an interview with the Director of Pharmacy Services (employee # 20), she stated that there is an IV room in the Medical - surgical ward. 3. During rounds and interviews with nursing supervisors (employees # 1, # 5, # 6, # 7, and # 40), they all stated that nursing staff perform reconstitution of antibiotics. 4. During interview with Director of Nursing (employee # 1) performed on 12/19/25 at 1:40 PM, she stated that nursing staff of medical - surgical ward are competent in compounding chemotherapies. Prior to this activity, staff must participate in an education course provided by an external resource. 5. The pharmacy policy named: “Manejo de Ordenes de Quimioterapia” Handling Chemotherapy Ordes (03/2025 revision) was discussed and reviewed with the Director of Pharmacy Services (employee # 20) on 12/19/2025 at 9:00 AM. a. The facility policy does not specify the level of supervision that the pharmacist will carry out during the preparation (compounding). 6. During round and interview with neonatal intensive care unit (NICU) nursing supervisor (employee # 40), performed on 12/19/2025 at 2:30 PM, she stated that the nursing staff perform mixing of drugs as ordered by the physician, depositing them in an empty bag named INTRAVIA Container before their intravenous administration. a. RR # 30 is a 19-day-old baby girl who was admitted on 11/30/2025 with a diagnosis of Respiratory Distress of Newborn. On 12/01/2025 the primary physician ordered the following mixture of IV drugs: 92 ml. of Dextrose in water 10 %, 7.6 ml. Sodium Chloride 3%, 12 ml. of Potassium Chloride, 2.5 ml. of Calcium Gluconate. The total volume was 114 ml. to run at a rate of 4.7 ml per hour. The mixing was prepared and administered by the registered nurse as ordered. b. RR # 31 is a 6-day-old baby girl who was admitted on 12/13/2025 with a diagnosis of Bacterial Sepsis of the Newborn. On 12/14/2025 the primary physician ordered the following mixture of IV drugs: 119 ml. of Dextrose in water 10 %, 12 ml. Sodium Chloride 3%, 20 ml. of Potassium Chloride, 4 ml. of Calcium Gluconate. The total volume was 155 ml. to run at a rate of 6.5 ml per hour. The mixing was prepared and administered by the registered nurse as ordered. 7. The facility failed to demonstrate that all compounding, packaging, and dispensing of drugs and biologicals are done under the supervision of a pharmacist.”

“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: 47632 Based on observations made in catheterization, operating room, and nuclear medicine from December 16, 2025, to December 19, 2025, it was determined that the facility failed to ensure that medications were in a secure area protected from access by unauthorized personnel. Findings include: 1. During observations made in the catheterization area, the following were found: a. On 12/17/2025 at 9:39 a.m., 25 vials of 200mg Propofol were found in a cabinet that was open. b. On 12/17/2025 at 9:53 a.m., two bottles of Serofluvace were found in the anesthesia machine, which was open. 2. During observations made in the Nuclear Medicine, the following was found: a. On 12/19/2025 at 1:28 PM, the following medications were observed in the channeling area: Two aminophylline 500 mg/20 ml injections. Four captopril 25 mg tablets. Nine 50 mg Benadryl tablets. Six 50 mg metoprolol tablets. Five 25 mg metoprolol tablets. Three vials of 1.25 mg Vasotec. One 40 mg Solumedrol. One 125 mg methylprednisolone. One bottle of 0.4 mg nitroglycerin. One vial of Benadryl 50 mg. Three capsules of Procardia 10 mg. Regadenoson 0.4/5 ml inj. One bottle of 10 chewable glucose tablets. One vial of dobutamine 250 mg/20 ml inj. The facility failed to ensure that medications stored in an accessible area were adequately protected from unauthorized personnel.”

“AFTER-HOURS ACCESS TO DRUGS CFR(s): 482.25(b)(4) When a pharmacist is not available, drugs and biologicals must be removed from the pharmacy or storage area only by personnel designated in the policies of the medical staff and pharmaceutical service, in accordance with Federal and State law. This Standard is not met as evidenced by: 51629 Based on interviews with the Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and document review performed on 12/19/2025 at 9:00 AM, it was determined that the facility failed to demonstrate that when a pharmacist is not available, drugs and biologicals are removed from pharmacy or storage area only by personnel designated in the policies of the medical staff and pharmaceutical service, in accordance with Federal and State law. Findings include: 1.During interview with the Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and document review performed on 12/19/2025 at 9:00 AM, she stated that the facility has mainly two methods for the routine after-hours access of medications: a night cabinet and automated storage (PIXYS), but no policy and procedure was provided related to: a.Designated non-pharmacist personnel allowed to obtain medications after pharmacy is closed. b.Training for the proper use of systems in place, including competence assessment of the personnel. c.Limited access to a set of medications that has been approved by the hospital. d.Quality control procedures (such as an independent second check by another individual) to prevent medication retrieval errors. 2.During a round in the medicine / surgery ward conducted on 12/17/2025 at 2:30 PM, there was an open box full of Clinolipid (lipid injectable emulsion) in the medication room. The facility did not maintain and demonstrate evidence of its performance improvement activities to monitor the routine after-hours access of medications thorough the hospital.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 47632 Based on observations made in the kitchen with the dietitian (employee# 13) on 12/16/2025 at 1:22 p.m., it was determined that the facility faild to ensure that food preparation equipment was clean, dry, and in good condition and that food was in good condition, protected, and labeled. Findings include: 1. During the tour of the kitchen with the diet manager (employee #13), the following was observed: a. Food residue was observed on the base of the blender with no evidence of cleaning after use. b. Moisture was observed on pots, metal trays, and pans. c. Tomato paste was observed uncovered. d. Rotten potatoes were observed. e. Open cooking oil without a lid was observed. f. An open box of tortillas was exposed in the freezer. g. Two boxes of vegetables were placed directly on the floor in the hallway at room temperature.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 47384 Based on observations made during the survey on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility failed to ensure that building areas are in optimal condition including the prevention of leaks in roofs and walls. Findings include: 1. During oservation performed on 12/16/2025 through 12/19/2025 ceiling tiles were found with water stains on the following areas: a. Catheterization Ward #1 room b. Surgery Ward OR #4 next to sprinkler head c. Surgery Ward OR #5 general area d. Room #285 e. Hallway in Central Medicine area 2. During oservation performed on 12/16/2025 through 12/19/2025 Monolithic walls and floors were found with defects the following areas: a. Catheterization Ward #1 room (wall) b. Surgery Ward OR #4 (wall and floor) 47632 3. During observations made in the kitchen on 12/16/2025 at 1:22 PM, the following was observed: a. The door leading to the pantry did not close. 51829 4.Observation of the medication room in the Hematology-Oncology unit conducted on December 18, 2025, at 11:00 AM. a. During a review of the unit with the supervisor (employee #43), it was identified that the medication room was changed for accessibility purposes, but it does not have a door to ensure privacy and a distraction-free area for security reasons. b. It does not have a sink to maintain infection control as required, nor does it have a suitable surface for medication preparation. c. The patient records are in the room and should be moved to the counter unit in a secure location, inaccessible to the public. This would reduce staff entry into the medication room and minimize distractions during medication preparation, thus ensuring patient safety.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47384 Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility’s Engineering Director and Safety Officer, it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101. Findings include: The Life Safety from Fire survey was performed from 9/16/2025 through 9/19/2025 from 8:00 am till 3:30 pm; for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS2567 form (K211, K221, K223, K225, K281,K291, K293, K321, K324, K342, K343, K345, K353, K355, K363, K753, K761, K781, K902, K904, K920, K923 and Tag K926).”

“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: 51782 Based on facility Emergency Department tour performed from 12/16/2025 to 12/19/2025, it was determined that the facility failed to ensure that facility is maintained an equipment in optimal conditions and to ensure an acceptable level of safety and quality, related to an nurses call accessible to the patients. Findings include: Facility policy provided by Emergency Room Supervisor (employee #9), on 12/17/2025 at 10:13 AM was reviewed. The policy was reviewed in March 2024, “Nurse Call - Llamado a enfermería” - “Nurse Call”. The policy states on page 1, that the cord of the nurse call should be kept close to or attached to the bed. 1. During the round made with the Emergency Room Supervisor (employee #9) in the emergency room department performed on 12/16/2025 through 12/17/2025 at 10:00 AM through 2:00 PM, the following was observed: a) The nurse call button cable was not accessible to the patient in the following rooms (observation area #1, #2, #3, #4, #5, #6, #7, #10, #11, #12, #13, #14 and #17), which compromised patient safety. 2. In the triage area, the following was observed: - Desk with cover lining deteriorated. 47632 3. During observations conducted with the operating room supervisor (employee 15), catheterization supervisor (employee 14), delivery room supervisor (employee 40), diet manager (employee 13), and technical coordinator (employee 36), the following were found: Kitchen: a. On 12/16/2025 at 1:22 PM, peeling paint and warped acoustic panels due to moisture were observed. Catheterization area: a. On 12/16/2025 at 2:27 p.m., a portable Oxygen tank was observed placed directly on the floor without a safety stand. b. On 12/16/2025 at 2:33 p.m., it was observed that the lead vests were placed on top of the trash can lid instead of on the lead vest hanger. c. On 12/16/2025 at 2:40 p.m., the following was observed in room #1: Two caterers expired on 05/25/25. Seven Tegaderm CHG expired 05/25/2025. Four blood collection sets expired 11/12/2025. Two temporary pacing catheters with shrouded plus introducer kits expired 09/30/2025. Crash cart: Cardiac monitor without preventive maintenance seal. Pulse oximeter without preventive maintenance seal. Suction machine without preventive maintenance seal. Observation of biomedical equipment without visible seals indicating preventive maintenance. The biomedical technician (employee#4) presented documented evidence that maintenance had been performed, but the facility failed to ensure adequate identification. Two packages of electrodes expired on 11/14/2027. Two PVC nasopharyngeal airways size 22 expired 04/25/2025. One bougie endotracheal tube #15 expired 11/10/2024. Operating room: c. On 12/17/2025 at 9:30 a.m., in room 2, the following was observed: One nasopharyngeal airway #26 expired 03/19/2025. Five endotracheal tube holders expired 02/2025. Three blood gas kits expired 10/2023. Four oral/nasal tracheal tubes 6.0 mm expired 09/15/2025. One size 8 laryngeal mask airway expired 04/03/2025. Four size 26 PVC nasopharyngeal airways expired 10/28/2025. Four 250 milliliter (ml) dextrose injections expired 11/2025. Sixteen radiolucent 5-lead electrode sets expired 05/17/2024. One warmer without preventive maintenance seal. One staple removal kit expired 11/09/2025. Anesthesia cart: Two bougie endotracheal tubes expired 11/10/2024. Four glidewine 0.035 expired 12/16/2025. Nineteen Angio seal 6Fr expired 11/17/2025. One multipurse drainage cat. Expired 12/06/2025. Ten pinnacle 7Fr expired 10/01/2025. One ST TBF carotid guiding sheath expired 09/01/2025. Quarter of medications: One vial of atropine sulfate 8 milligrams (mg)/20ml expired 05/2025. One methylprednisolone 40mg/2ml expired 10/2024. Two metoclopramide 10mg/2ml expired 11/30/2025. Three ketorolac 60mg/2ml expired 08/2025. Pre-anesthesia: Two cardiac monitors with last preventive maintenance in 07/2018. Three warmers with last preventive maintenance in 2015 and 2024. Five expired suction caterers with expiration dates of 05/23/2025, 01/2023, 03/30/2025, and 02/2021. Three vital signs machines without preventive maintenance seals. Crash cart located in the operating room hallway: a. On 12/17/2025 at 2:02 p.m., a defibrillator without a preventive maintenance seal was observed. Operating room: a. On 12/17/2025 at 2:11 p.m., one anesthesia machine without a preventive maintenance seal was observed in room 1. b. On 12/17/2025 at 2:13 p.m., the anesthesia cart was observed in room 1: One Yankauer suction expired on 04/01/2025. One 10 Calcium chloride 1000mg/10 ml expired 07/2025. Two microbere extension sets expired 07/11/2021. Nine 6.0mm endotracheal tubes expired 09/24/2024 and 08/25/2025. Two 6.5mm endotracheal tubes expired 02/19/2025. c. On 12/17/2025 at 11:30 a.m., the following was observed in the recovery area on the malignant hyperthermia cart: Eight blue Dr citrate tubes expired 11/30/2025. One Foley catheter #18 expiring on 05/31/2025. Recovery: a. On 12/18/2025 at 11:45 a.m., the following was observed in the cart: Two warmers with expired preventive maintenance stamps. 01/2024. Delivery room: a. On 12/19/2025 at 9:41 a.m., it was observed in rooms 1, 2, and 3 that three incubators had undergone their last preventive maintenance in 03/2019. Nuclear medicine: a. On 12/19/2025 at 1:49 p.m., it was observed in the parking cart that the suction machine was deteriorated with dark spots. b. On 12/19/2025 at 1:51 p.m., it was observed that an oxygen tank was placed directly on the floor without safety support. Lack of preventive maintenance seal on the Saturometer.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47632 Based on observations made in the nuclear medicine and operating room standards and procedures manual from December 16, 2025, to December 19, 2025, it was determined that the facility failed to ensure that the manual and infection control policies were updated and that infection prevention practices were followed during procedures. Findings include: 1. During observations made on 12/18/2025 at 10:16 AM, in procedure P.R. # 20, a 53-year-old male admitted on 12/16/2025 with permanent catheter for dialysis, the following was observed during the procedure: a. On 12/18/2025 at 10:16 AM, the circulating nurse (employee #16) on two occasions after discarding gloves did not wash her hands with soap and water or hand sanitizer before putting on clean gloves. b. On 12/18/2025 at 10:22 AM, the anesthesiologist (employee #18) was observed on two occasions entering room #2 without wearing sterile pants and shoe covers. Fatal use of personal protective equipment inside the room. c. On 12/18/2025 at 10:24 AM, the anesthesiologist (employee #18) was observed on two occasions after discarding gloves and not washing his hands with soap and water or hand sanitizer before putting on clean gloves. d. On 12/18/2025 at 10:33 AM, the anesthesia supervisor (employee #19) was observed after discarding gloves and not washing her hands with soap and water or hand sanitizer before putting on clean gloves.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 51782 Based on the observational tour in the Emergency Room Department performed on 12/16/2025 through 12/19/2025 from 9:00 AM through 4:00 PM, and Medicine Surgery Ward performed on 12/17/2025 at 2:30 PM, it was determined that the facility failed to include method for preventing and infection control, including maintaining a clean and sanitary environment within the hospital. Findings include: 1. During the round made with the Emergency Room Supervisor (employee #9) in the emergency room department area on 12/16/2025 at 1:15 PM through 3:45 PM, the following was observed: a) At 1:45 PM, in the trauma room on emergency room department: - Two adult-pediatric chest drainage unit expired on 11/22/2025. - Nineteen sterile gloves size 8.5 expired on 10/31/2025. b) At 2:35 PM, in the medicine room, intravenous bags boxes directly on the floor. 51629 2. During a round performed with Medicine Surgery Ward Supervisor (employee # 6) on 12/17/2025, 2:30 PM, the following was observed: a. RR # 48 is a 59-year-old female who was admitted on 10/21/2025 with a diagnosis of Candidal Stomatitis. Room # 232. The patient was on a bed with rust all around, including its base and side railings. Also, there was a height adjustable over bed dining table with rust on the base. b .RR # 49 is a 41-year-old male who was admitted on 11/24/2025 with a diagnosis of Acute Lymphoblastic Leukemia. Room # 232. The patient was on a bed with rust all around, including its base and side railings. c. One medication cart with rust at the top base over the bins. 47632 3. During observations conducted with the operating room supervisor (employee 15), catheterization supervisor (employee 14), delivery room supervisor (employee 40), diet manager (employee 13), and technical coordinator (employee 36), the following were found: Kitchen: During the tour of the kitchen with the diet manager (employee #13) on 12/16/2025 at 1:22 PM, the following was observed: a. Food residue was observed on the base of the blender with no evidence of cleaning after use. b. Moisture was observed on pots, metal trays, and pans. c. Tomato paste was observed uncovered. d. Rotten potatoes were observed. e. Open cooking oil without a lid was observed. f. An open box of tortillas was exposed in the freezer. g. Two boxes of vegetables were placed directly on the floor in the hallway at room temperature. Catheterization area: a. On 12/16/2025 at 2:25 PM, observed a box of shoe covers placed in a biohazard bin. This exposed the supply to cross-contamination. b. On 12/16/2025 at 2:32 PM, an open bin with tape stuck to the wall to prevent the lid from closing was observed in room #1. This exposed the patient and staff to the risk of contamination. c. On 12/16/2025 at 2:33 p.m., it was observed that the lead vests were placed on top of the trash can lid instead of on the lead vest hanger. This exposed the lead vests to cross-contamination. Operating room maintenance room: a. On 12/17/2025 at 2:05 PM, observed a lack of designated red bins for mapping in each room, which puts them at risk of cross-contamination. Operating room: a. On 12/17/2025 at 2:31 PM, it was observed in room #1 that the surgical lamp had peeling paint and dark spots, and the wall had a hole and moisture. b. On 12/17/2025 at 2:38 PM, stains and moisture were observed on the ceiling in room #5. Nuclear medicine: a. On 12/19/2025 at 2:00 p.m., a container of egg whites was observed in the refrigerator along with three vials of Cardizem inj 25 mg/5 ml. 51829 4. During observations and reviews conducted accompanied by the Director of Institutional Programs (employee #23), the Infection Control Coordinator (employee #24), and the Quality Coordinator (employee #25), it was identified that the Facility did not guarantee compliance with best practices for prevention, patient safety, and infection control to prevent and minimize infections. Deficiencies were identified in handwashing: a. The hospital’s hand hygiene policy clearly establishes the procedure, duration, and precautions. It also includes the times when handwashing is required and references regulatory bodies such as the World Health Organization-WHO (October 2010) and their illustrated posters. The policy is dated June 2022; however, the following was identified: i. On December 17, 2025, at 2:04 pm, the registered nurse (employee #31) put on gloves to receive a patient transferred from the operating room, and no prior handwashing was observed. ii. On December 18, 2025, at 10:00 am, the registered nurse (employee #32) washed his/her hands, and when removing the paper towel, it fell onto the sink. iii. On December 18, 2025, at 12:01 pm, the respiratory therapy supervisor (employee #29) washed hands without removing the paper towel. iv. On December 18, 2025, at 12:06 pm, the pulmonologist (employee #28) washed hands but did not perform the procedure thoroughly or for the minimum washing time requirement. 5. Expired medical-surgical supplies were identified in different units. a. The hospital’s crash cart verification policy, reviewed in December 2025, establishes the verification of medical surgical supplies, which includes a checklist and designates a nursing professional as the personnel responsible. b. In medical unit #3, accompanied by the unit supervisor (employee #26), on December 17, 2025, at 2:42 pm, the following was identified: In crash cart #1, the following expired supplies were found: 1 Bougi bottle dated June 2024. In crash cart #2, the following were identified: i. Central line (1) dated September 18, 2025 ii. 0.9% saline solution, 250 ml (1) dated August 2025 iii. NSS 0.45% of 1000 dated 11/2025 6. The following items were identified in crash cart #3: i. 3M defibrillator patch dated 04/04/2025 ii. 135 mm adult Macv 4 disposable blades (2) dated 11/2025 iii. Green venipuncture tubes (2) dated 10/31/2025 c. In the Gynecology-Nursery unit, accompanied by the supervisor (employee # 5), on 12/18/2025 at 2:00 pm, expired material was identified in the medicine room: Gray colored tubes (3) dated 06/30/2025. d. In Medical Unit 2, accompanied by the supervisor (employee #27) on 12/18/2025 at 2:29 pm, there was no evidence of a review of the medical-surgical supplies by the assigned personnel or the supervisor, although the assigned personnel were present at the work assignment for the shift and had the established checklist. Expired supplies were identified: 1.Crash Cart #1: i. Catheterization tray (1) dated 07/28/2024 ii. Open urethral tray 14 fr. (1) dated 01/09/2025 iii. Adult electrodes (91) dated 03/26/2024 iv. Blood culture tubes (3) dated 10/19/2024 v. Secondary lines (3) dated 02/2025 vi. Suction catheter (1) dated 08/31/2024 vii. 250 ml 0.9% NSS (3) dated 08/2025 viii. Chloraped (2) dated 10/20/2024 ix. Adult colorimetric CO2 detector (1) dated 05/17/2024 x. Needles (7) dated 07/08/2025 xi. 6.5 mm endotracheal tube (1) dated 04/24/2025 and (2) dated 01/05/2024 and 8.0 mm endotracheal tube (1) dated 08/26/2024 xii. Blood Gas Kit (1) dated 03/2025 xiii. Blue tubes (5) dated 11/30/2025 7. Crash cart # 2: i. Foley Catheter (3) dated 05/31/2024, 09/30/2024 and 05/31/2025 ii. Endotracheal bougie tube-introducer (2) dated 12/19/2024 iii. Foley tray (1) dated 03/21/2025 iv. Insulin syringes (4) dated 06/11/2025 v. Staple Removal kit (1) dated 02/24/2025 vi. Blood culture tubes (2) dated 07/17/2025 vii. Adult Colorimetric CO2 Detector (1) dated 10/27/2025 viii. 6.5 endotracheal tubes (2) dated 10/27/2025 and one expired and broken tube dated 04/24/2025 ix. Teleflex (1) dated 12/28/2021 x. Blue tubes (3) dated 12/28/2025 8. Medication room with expired materials: i. Adult SpO2 monitor (1) dated 06/30/2025 ii. Needles #25 x 5/8 (14) - 2024 iii. Angio catheter #16 G x 1 with 1/4 in (9) - 11/15/2025 iv. Vac Dermatac (2) - 01/31/2025 v. Gastrostomy tube (1) - 04/13/2025 9. In the medical-surgical supply warehouse, on 12/19/2025 at 10:23 am, the following expired materials were identified: i. T-tube in a Ziploc bag without a date and without the sterile wrapper ii. Feeding tube (1) - 05/31/2025 iii. 1 ml syringe (1) - 11/31/2025”

“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 observations made in the catheterization, operating room, delivery room, and nuclear medicine areas from December 16, 2025, to December 19, 2025, it was determined that the facility failed to ensure that there was an educational plan for each department. Findings include: During interviews conducted on 12/19/2025 from 11:10 AM to 2:03 PM with the operating room supervisor (employee #15) and anesthesia supervisor (employee #19), they presented the training plan, which did not include training on hand hygiene, personal protection, cleaning of non-critical, semi-critical, and critical equipment, among other topics.”

“ABX STEWARDSHIP LEADERSHIP PROGRAM CFR(s): Standard: Leadership responsibilities (3) The leader(s) of the antibiotic stewardship program is responsible for: (i) The development and implementation of a hospital-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics. This Standard is not met as evidenced by: 51629 Based on interviews with the Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and document review performed on 12/19/2025 at 9:00 AM, it was identified that the facility failed to develop and implement a hospital - wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics. Findings include: 1. During interview with the Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and document review performed on 12/19/2025 at 9:00 AM, she stated that: a. The antibiotic stewardship program has not held any meeting since 2022. Instead of that, the director of pharmacy (employee # 20) stated that she held individual meetings with the leaders associated with antibiotic use. b. The committee record file shows one minute (04/01/2022). The facility failed to provide evidence of the development and implementation of hospital - wide antibiotic stewardship program.”

“ABX STEWARDSHIP LEADERSHIP DOCUMENTATION CFR(s): [The leader(s) of the antibiotic stewardship program is responsible for:] (ii) All documentation, written or electronic, of antibiotic stewardship program activities. This Standard is not met as evidenced by: 51629 Based on interviews with the Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and document review performed on 12/19/2025 at 9:00 AM, it was identified that the facility failed to provide evidence of all documentation (written or electronic), of antibiotic stewardship program activities. Findings include: 1. During interview with the Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and document review performed on 12/19/2025 at 9:00 AM, she stated that: a. The antibiotic stewardship program has not held any meeting since 2022. Instead of that, the director of pharmacy (employee # 20) stated that she held individual meetings with the leaders associated with antibiotic use. b. The committee record file shows one minute (04/01/2025). The facility failed to provide evidence of all documentation (written or electronic), of antibiotic stewardship program activities.”

“ABX STEWARDSHIP LEADERSHIP COMMUNICATION CFR(s): This Standard is not met as evidenced by: 51629 Based on interviews with the Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and document review performed on 12/19/2025 at 9:00 AM, it was identified that the facility failed to evidence communication and collaboration with medical staff, nursing, and pharmacy leadership, as well with the hospital’s infection prevention and control and Quality Assessment and Performance Improvement Program -QAPI, on antibiotic use issues. Findings include: 1. During interview with the Director of Pharmacy Services (employee # 20) performed on 12/18/2025 at 3:00 PM, 12/19/2025 at 9:00 AM, and document review performed on 12/19/2025 at 9:00 AM, she stated that: a. The antibiotic stewardship program has not held any meeting since 2022. Instead of that, the director of pharmacy (employee # 20) stated that she held individual meetings with the leaders associated with antibiotic use. b. The committee record file shows one minute (04/01/2022). The facility failed to provide evidence of communication and collaboration among the interdisciplinary team, on antibiotic use issues.”

“REQUIRED OPERATING ROOM EQUIPMENT CFR(s): 482.51(b)(3) The following equipment must be available to the operating room suites: call-in system, cardiac monitor, resuscitator, defibrillator, aspirator, and tracheotomy set. This Standard is not met as evidenced by: 47632 Based on observations made in the operating rooms with the operating room supervisor (employee 15) and anesthesia supervisor (employee 19) from December 16, 2025, to December 19, 2025, it was determined that the facility failed to ensure that biomedical equipment in use had preventive maintenance seals. Findings include: Catheterization area: a. Crash cart: Cardiac monitor without preventive maintenance seal. Saturation monitors without preventive maintenance seal. Suction machine without preventive maintenance seal. b. On 12/17/2025 at 9:30 a.m., the following was observed in room 2: One warmer without a preventive maintenance seal. Pre-anesthesia: Two cardiac monitors with last preventive maintenance in 07/2018. Three warmers with last preventive maintenance in 2015 and 2024. Three vital signs machines without preventive maintenance seals. Crash cart located in the operating room hallway: On 12/17/2025 at 2:02 p.m., a defibrillator without a preventive maintenance seal was observed. Operating room: On 12/17/2025 at 2:11 p.m., an anesthesia machine without a preventive maintenance seal was observed in room 1. Biomedical equipment was observed without a visible seal indicating preventive maintenance. The biomedical technician (employee #4) presented documented evidence that maintenance had been performed, but the facility failed to ensure proper identification.”

“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 Supervisor (employee #3), it was determined that the facility failed to ensure the credentials files (CF) qualification are updated for respiratory therapy personnel for 5 out of 6 CF reviewed (CF #1, # 2, 3, 4, and 5). Findings include: 1. During review of six personnel credential files performed on 12/19/2025 from 2:20 PM through 2:45 PM provided evidence of the following: a) Five out of six credential files failed to show updated evidence of influenza vaccine or the exoneration form for influenza vaccine (C.F #1, #2, #3, #4, #5). b) One out of six credential files failed to show evidence of annual evaluation (C.F #1). c) One out of six credential files failed to show updated evidence of competencies (C.F #2, #3).”

“RESPIRATORY SERVICES CFR(s): 482.57(b)(4) All respiratory care services orders must be documented in the patient’s medical record in accordance with the requirements at §482.24. This Standard is not met as evidenced by: 51782 Based on the five medical records reviewed (R.R) and policies/procedures with the respiratory therapist supervisor (employee #10), it was determined that the facility failed to ensure that respiratory therapy services orders must be documented in the patient’s medical record in accordance with the requirements, related to the frequency of the treatments and progress notes document for 5 out of 5 records reviewed (R.R. #14, #15, #16, #17 and #18). Findings include: Facility policy provided by Respiratory Therapy Supervisor (employee #10), on 12/18/2025 at 9:49 AM was reviewed. “Documentación del terapista respiratorio en el récord electrónico” - “Respiratory therapist documentation in the electronic record”. The policy states on page 1 section 3 that the respiratory therapist is responsible for documenting all care and treatment provided to the patient. Facility policy provided by Respiratory Therapy Supervisor (employee #10), on 12/18/2025 at 9:49 AM was reviewed. “Horario de los tratamientos y/o procedimientos” - “Schedule of treatments and/or procedures”. The policy states on page 1 that it is the department’s policy to maintain uniformity in treatment schedules. The frequency for treatments every 4 hours is as follows: 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM, 12:00 AM, and 4:00 AM. Five active R.R were reviewed from 12/17/2025 to 12/18/2025 from 9:00 AM to 3:45 PM of patients receiving respiratory therapy and provided evidence that the physician’s orders are not carried out as ordered, the frequency of the treatments is not in accordance with the medical order and the respiratory therapists were not documenting the progress notes on all shifts for (R.R#14, #15, #16, #17 and #18). The R.R provided evidence that the respiratory therapist failed to provide therapy to the patient in accordance with the physician’s orders. 1. R.R #14 is a 57-year-old male who was admitted on 12/16/2025 with a diagnosis of unspecified congestive heart failure, influenza. The R.R was performed on 12/17/2025 at 3:25 PM, with the respiratory therapist supervisor (employee #10), provided evidence that on 12/16/2025 at 12:39 AM the physician ordered Atrovent 0.02% / 3ml saline one ampule by power nebulizer (P.N) every fifteen minutes then every four hours. On 12/16/2025, during the shifts from 7:00 AM to 3:00 PM the respiratory therapist, the nebulizer treatment administrated was documented at 11:00 AM and 12/17/2025 during the shifts from 7:00 AM to 3:00 PM the respiratory therapist, the nebulizer treatment administrated was documented at 10:00 AM. No evidence was found that the therapist provided respiratory therapy in accordance with the frequency at 8:00 AM and/or 12:00 PM. The facility’s respiratory therapist failed to provide therapy to the patient in accordance with the physician’s orders. It was also observed that on 12/16/2025, during shifts from 3:00 PM to 11:00 PM, the respiratory therapist did not document these administrations in the patient’s progress notes. 2. R.R #15 is a 59-year-old male who was admitted on 12/15/2025 with a diagnosis of Sepsis, Acute Bronchitis. The R.R was performed on 12/18/2025 at 10:50 AM, with the respiratory therapist supervisor (employee #10), provided evidence that on 12/15/2025 at 11:15 AM the physician ordered Albuterol 0.083% / 3ml saline one ampule by P.N every four hours and Atrovent 0.02% / 3ml saline one ampule by P.N every four hours. On 12/17/2025, during the shifts from 7:00 AM to 3:00 PM the respiratory therapist, the nebulizer treatment administrated, was documented at 11:00 AM and on 12/17/2025 during the shifts from 11:00 PM to 7:00 AM the respiratory therapist, the nebulizer treatment administrated was documented at 1:15 AM. No evidence was found that the therapist provided respiratory therapy in accordance with the frequency at 8:00 AM and/or 12:00 PM for the shift 7:00 AM to 3:00 PM and 12:00 AM and/or 4:00 AM for the shift 11:00 PM to 7:00 AM. The facility’s respiratory therapist failed to provide therapy to the patient in accordance with the physician’s orders. It was also observed that on 12/16/2025, during the shifts from 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM, the respiratory therapist did not document these administrations in the patient’s progress notes. 3. R.R #16 is a 34-year-old female who was admitted on 12/16/2025 with a diagnosis of asthma exacerbation. The R.R was performed on 12/18/2025 at 11:10 AM, with the respiratory therapist supervisor (employee #10), provided evidence that on 12/16/2025 at 3:00 PM the physician ordered Albuterol 1.25mg / 3ml saline one ampule by P.N every six hours and Atrovent 0.02% / 3ml saline one ampule by P.N every six hours. On 12/16/2025, during the shifts from 3:00 PM to 11:00 PM, the respiratory therapist did not document these administrations in the patient’s progress notes. 4. R.R #17 is a 40-year-old male who was admitted on 12/16/2025 with a diagnosis of bronchopneumonia. The R.R was performed on 12/18/2025 at 11:31 AM, with the respiratory therapist supervisor (employee #10), provided evidence that on 12/16/2025 at 8:30 AM the physician ordered Proventil 0.083% / 3ml saline one ampule by P.N every four hours. On 12/17/2025, during the shifts from 7:00 AM to 3:00 PM the respiratory therapist, the nebulizer treatment administrated was documented at 11:00 AM. No evidence was found that the therapist provided respiratory therapy in accordance with the frequency at 8:00 AM and/or 12:00 PM. The facility’s respiratory therapist failed to provide therapy to the patient in accordance with the physician’s orders. It was also observed that on 12/16/2025, during the shifts from 3:00 PM to 11:00 PM and on 12/17/2025, during the shifts from 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM, the respiratory therapist did not document these administrations in the patient’s progress notes. 5. R.R #18 is a 57-year-old female who was admitted on 12/17/2025 with a diagnosis of hypercapnia, respiratory failure. The R.R was performed on 12/18/2025 at 11:45 AM, with the respiratory therapist supervisor (employee #10), provided evidence that on 12/17/2025 at 9:45 AM the physician ordered Albuterol 1.25mg / 3ml saline one ampule by P.N every six hours and Atrovent 0.02% / 3ml saline one ampule by P.N every six hours. On 12/17/2025, during the shifts from 7:00 AM to 3:00 PM the respiratory therapist, the nebulizer treatment administrated was documented at 2:58 PM. No evidence was found that the therapist provided respiratory therapy in accordance with the frequency at 8:00 AM and/or 12:00 PM. The facility’s respiratory therapist failed to provide therapy to the patient in accordance with the physician’s orders. It was also observed that on 12/17/2025, during shifts from 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM, the respiratory therapist did not document these administrations in the patient’s progress notes.”

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Emergency Preparedness on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38), to evaluate emergency preparedness requirements, it was determined that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials’ effort to maintain an integrated response during disaster or emergency. Findings include: During the review of the facilities Emergency Preparedness Program with Safety Officer it was noted that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials as required under §482.15 of the Emergency Preparedness.”

“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 on observations made during the survey for Emergency Preparedness on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38), to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer 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 on observations made during the survey for Emergency Preparedness on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) 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 patients. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer it was noted that the facility 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.”

“Primary/Alternate Means for Communication CFR(s): §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Emergency Preparedness on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38), to evaluate emergency preparedness requirements, it was determined that the facility failed to develop primary / alternate means for communication with HHA’s staff, Federal, State regional and local emergency management agencies in compliance with Federal, State and local laws. Findings include: During the review of the facilities Emergency Preparedness Program with the Safety Officer it was noted that the facility failed to provide evidence of the Emergency Preparedness Communication Plan that included primary and alternate means for communicating with the facility staff, Federal, State, regional and local emergency management agencies under §482.15(c)(3).”

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Emergency Preparedness on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38), to evaluate emergency preparedness requirements, it was determined that the facility failed to provide a method for sharing information and medical documentation for patients under the facility’s care, as necessary, with other health care providers to maintain the continuity of care. Findings include: During the review of the facilities Emergency Preparedness Program with Safety Officer (employee #38) it was noted that the facility failed provide a written method for sharing information and medical documentation for patients under the facility’s care, as necessary, with other health care providers to maintain the continuity of care as required under §482.15(c)(4)-(6).”

“Information on Occupancy/Needs CFR(s): §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Emergency Preparedness on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38), to evaluate emergency preparedness requirements, it was determined that the facility failed to have written means of providing information about the facility’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. Findings include: During the review of the facilities Emergency Preparedness Program with the Dafety Officer (employee #38) it was noted that the facility failed to have written procedures of providing information about the facility’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center.”

“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 made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility failed to maintain the width of aisles or corridors serving as exit access at least 4 feet and maintained to provide the convenient removal of non-ambulatory patients 19.2.3.4, 19.2.3.5. Findings include: 1. Approximately at 10:30 AM on 12/16/2025 two (2) unattended Nitrogen tanks were observed obstructing pathway to exit door near OR #1 in the Surgery Department. 2. Approximately at 11:30 AM on 12/17/2025 unattended medicine cart and and a sphygmomanometer were observed on both sides of corridor in the medicine department area reducing exit access to less than three-foot six inches wide. The finding was verified by the Engineering Manager and Safety Officer at the time of the observation.”

“Patient Sleeping Room Doors CFR(s): NFPA 101 Patient Sleeping Room Doors Locks on patient sleeping room doors are not permitted unless the key-locking device that restricts access from the corridor does not restrict egress from the patient room, or the locking arrangement is permitted for patient clinical, security or safety needs in accordance with 18.2.2.2.5 or 19.2.2.2.5. 18.2.2.2, 19.2.2.2, TIA 12-4 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility did not ensure to prevent locks on patient sleeping room doors in accordance with 18.2.2.2.5 or 19.2.2.2.5 / 18.2.2.2, 19.2.2.2, TIA 12-4 Findings include: 1. During visual inspection of the second floor Medicine Department at approximately 2:00 PM it was noticed that Patient Room #214 had a key lock on the room entrance door. The finding was verified by the Engineering Manager and Safety Officer at the time of the observation.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 47384 Based on observations and interviews made during the survey for Life Safety from Fire of the Hospital with the facility’s Engineering Manager (Employee #39) and the Safety Officer (employee #38), it was determined that the facility failed to comply with Life Safety Code 2012 Edition, Section 19.3.7.3, 8.6.7.1(1) . Findings include: 1. Observation and interview on 12/17/2025 revealed that smoke barrier doors with self-closing device located throughout the facility did not work properly due to board alarm system problems. The finding was verified by the Engineering Manager and Safety Officer at the time of the observation.”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility failed to comply with NFPA 101 / 7.2 for Stairways and Smokeproof enclosures. Findings include: During visual inspection with the facility Safety Officer (Employee #38) and Engineering Director (employee #39), it was noted that the stairway did not provide special signage within the enclosure at each floor landing in accordance with NFPA 101 / 7.2. The finding was verified by the Safety Officer and Engineering Director”

“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 made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), 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: Pathway from ramp to outside building of approximately 45 feet long serving as an exit access and means of egress from Emergency Ward had no egress lighting. The finding was verified by the Safety Officer and Engineering Director”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), the facility failed to to have emergency lighting in accordance with 7.9, 18.2.9.1, 19.2.9.1. Findings include: Emergency light was observed with one (1) of two (2) broken lamps. The finding was verified by the Safety Officer and Engineering Director”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility failed to provide compliant exit signs in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA 101 Sections 19.2.9.1, 7.9, 7.9.2, 7.9.2.3, 7.9.3.1.1, 7.10.9, 19.2.10, 7.10, 7.10.1.2.1, 7.10.7.2, 7.10.8, 7.10.8.1, 7.10.5, 7.10.6.3, 7.10.7, 7.10.7.1, 7.10.9.1 and 19.2.10.1. Findings include: 1. During the observational tour of the hospital on 12/16/2025 from 8:30 AM till 3:30 PM, it was noticed that there was no exit sign on exit door next to OR #5. 2. During the observational tour of the hospital on 12/16/2025 from 8:30 AM till 3:30 PM, it was noticed that there was no exit sign next to the dietitians office. 3. During the observational tour of the hospital on 12/17/2025 from 8:30 AM till 3:30 PM, it was noticed that there was no exit sign on exit door of main waiting area of the Emergency Ward. 4. During the observational tour of the hospital on 12/17/2025 from 8:30 AM till 3:30 PM, it was noticed that exit sign in front of mens bathroom and cubicule #10 should be relocated in order to be visible from all areas. The findings were verified by the Engineering Manager and Safety Officer 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 made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), faclity failed to ensure 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. Findings include: During visual observation of the Autoclave area on the Surgery Department, it was noticed that fire wall was not constructed top to bottom, some penetrations were observed leaving space on the plenum. The finding was verified by the Safety Officer and Engineering Director”

“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 a recertification survey, observations made during the life safety from fire, it was determined that the facility failed to ensure that cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Findings include: During observational tour for Life Safety from Fire on 12/16/2025 at approximately 10:05 AM with the facilty’s Engineering Director (employee #39) and the Safety Officer (employee #38) the following was noticed in the Diet Department. 1. Grease Baffles not properly installed leaving approximately 2” gap into the exhaust hood system. 2. Rubber Blow Off Caps Fire Suppression Nozzles were missing on 3 of the ANSUL nozzles of the system. 3. ANSUL manual activation device did not have monthly inspection card filled up with dates. The finding was verified by the Safety Officer and Engineering Director”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility failed to efectively maintain initiation of the fire alarm system by manual means and by detection device, or detection system as required in (NFPA101) 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5. Findings include: 1. At approximately 10:45 AM on 12/016/2025, it was noticed that dispositives (smoke detectors) in various areas of the Hospital were inoperable. Surveyor proceded to question the Engineering Director about what was noticed, to what the Engineering Director replied that there was a problem with the board of the alarm system panel. Engineering Director stated that dispositives as smoke detectors, heat detectors, pull stations and water flow sensors were being afected by the problem on the board but that they had stablished a Interim Life Safety plan since 08/28/2025 when the problem was detected. Evidence of this plan was submited to the Surveyor. 2. Some areas were smoke detectors are required were observed without device: a. Emergency Ward, Registry area b. Emergency Ward, Trauma / Minor Surgery room c. CT #1, X Ray area d. CT #2, X Ray area e. MRI #1, X Ray area The finding was verified by the Safety Officer and Engineering Director.”

“Fire Alarm System - Notification CFR(s): NFPA 101 Fire Alarm - Notification 2012 EXISTING Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire. 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1) This Standard is not met as evidenced by: 47384 Based on observation and interview, it was determined that the facility failed to ensure that occupant notification is provided automatically in accordance with NFPA 101, 2012 Edition, Section 9.6.3 by audible and visual signals. Findings include: Observation and interview performed form 12/16/2025 through 12/19/2025 revealed that there are no visual (strobe) or audible signals in public area bathrooms. The finding was verified by the Safety Officer and Engineering Director”

“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 observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility failed to have a fire alarm system that 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. Findings include: 1) Fire alarm annunciator reported 223 trouble signals that were not restored to normal within 200 seconds. The finding was verified by the Safety Officer and Engineering Director”

“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 made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), the facility failed to comply with Life Safety Code 2012 Edition, Section 9.7.5, 9.7.7, 9.7.8, NFPA 25, 2011 Edition 13.2.7.2. Findings include: 1. Observation and interview on 12/18/2025, at approximately 1:30 PM revealed main sprinkler riser and sprinkler gauge were dated 2011. No documentation available for the five-year calibration report for this gauges. 2. Loaded sprinkler heads were observed in: a. Rooms 271 and 272 b. First floor lobby c. Registry area, admitions area and waiting arae of the Emergency Ward d. Intensive Care unit in front of warehouse The finding was verified by the Safety Officer and Engineering Director”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), 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 12/16/2025 approximately at 9:30 AM a ABC and BC fire extinguishers were observed blocked by a Lead Apron rack and trash can in the catheterization ward. 2. On 12/16/2025 approximately at 9:40 AM a ABC fire extinguisher was observed blocked by surgical equipment cart next to Dirty linen room in the catheterization ward. 3. On 12/16/2025 approximately at 10:30 AM a ABC fire extinguisher was observed blocked by radiology machine in the Surgery Ward between OR #2 and OR #3. 4. On 12/16/2025 approximately at 10:35 AM a ABC fire extinguisher was observed with no inspection since October 2024. 5. On 12/17/2025 approximately at 10:35 AM a ABC fire extinguisher was observed with blocked by a table with medical equipment in the Delivery Ward. Extinguisher was inspected in September and monthly inspection card was first signed in December. 6. On 12/17/2025 approximately at 1:30 PM a ABC fire extinguisher was observed blocked by a EKG machine in the Intensive Care Unit. 7. On 12/17/2025 approximately at 1:30 PM a ABC fire extinguisher was observed blocked by a crash cart in the Intensive Care Unit. 8. Extinguisher throughout the facility should be checked to comply with the 5 feet maximum height for extinguishers not exeeding 40 pounds. The finding was verified by the Engineering Manager and Safety Officer at the time of the observation.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility failed to protect corridors at clinical floors ( doors do not latch) as required by the 2012 edition of the Life Safety Code of the NFPA Section 19.3.6.3. Findings include: During the tour for life safety from fire, patient’s sleeping room doors were tested and it was found that doors 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. Maternity Ward: #234, #235, #236, #250, #251, #253, #254 Second Floor Medicine: #270, #271, #272,#287 The finding was verified by the Safety Officer and Engineering Director”

“Combustible Decorations CFR(s): NFPA 101 Combustible Decorations Combustible decorations shall be prohibited unless one of the following is met: o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product. o Decorations meet NFPA 701. o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289. o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present. 19.7.5.6 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility failed to prohibit combustible decorations on the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). Findings include: 1. Christmas decorations (garlands) were seen hanging from the ceiling near the sprinklers heads throughout all the facility. 2. Three doors on the Emergency Ward Registry area were observed with christamas ornaments and paper raping. The finding was verified by the Safety Officer and Engineering Director”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39),it was determined that the facility failed to ensure fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (2010 NFPA 80). Findings include: After review of document “Fire and Smoke Door Inspection performed on May 30, 2025, at the moment of the survey it was found that 21 out of 38 smoke and fire doors do not comply with NFPA 80. The finding was verified by the Safety Officer and Engineering Director”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility failed to maintain areas free of portable space heating devices. 18.7.8, 19.7.8 Findings include: 1. Two Portable heaters was obseverd on Nuclear Medicine Department. The finding was verified by the Safety Officer and Engineering Director”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was observed that the facility dis not ensure the emergency shutoff valves are free of obstacles. Findings include: 1. On 12/16/2025 at apporoximately 3:15 PM the shutoff valve for OR #5 was observed obstructed by Sterile Water Heater. 2. On 12/17/2025 at apporoximately 10:10 AM the shutoff valve for Delivery Room area was observed obstructed by a sphygmomanometer. 3. On 12/17/2025 at apporoximately 1:00 PM the shutoff valve for Medicine 2 area was observed obstructed by a christmas tree. 4. On 12/17/2025 at apporoximately 3:30 PM the shutoff valve for Emergency Ward ambulance personel area was observed obstructed by a patients in stretchers. The finding was verified by the Safety Officer and Engineering Director.”

“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 made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility failed to ensure all master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable. 5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99) Findings include: A pattern of non labeling the Medical Gas outputs was observed throughout the facility. The finding was verified by the Safety Officer and Engineering Director”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility failed to have Hospital grade power cords or multy plugs in hospital areas as required in 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 Findings include: 1. One (1) un authorized electrical extention cord with a four (4) receptacle outlet on catheterization room #2. 2. Electric cable was observed cut and covered with brown non electrical tape in the Autoclave Room. 3. One (1) un authorized electrical extention cord (red and black) in Surgery room #2 in the Surgery Department. The finding was verified by the Safety Officer and Engineering Director”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for Life Safety from Fire on 12/16/2025 through 12/19/2025 from 8:00 AM to 4:00 PM with the facility’s Safety Officer (Employee #38) and Engineering Director (employee #39), it was determined that the facility failed to observe precautionary measures to ensure safety on the cylinder storage as requested on 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) Findings include: 1. Unprotected type E tank was observed on the floor in front of catheterization room #1. 2. Unprotected type E and Type K tanks were observed on the floor in the Education Department. 3. The signage where the medical gas tanks are stored (enclosure) was observed to be discolored and should be checked from all sides. The finding was verified by the Safety Officer and Engineering Director.”

“Gas Equipment - Qualifications and Training CFR(s): NFPA 101 Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observation and interview the facility failed to ensure that personnel responsible for the application, maintenance and handling of medical gases are trained on the risks, and safety requirements including medical gas shut off are trained in the event of an emergency in accordance with the requirements of NFPA 99, 2012 Edition, Section 11.5.2.1. Findings include: Observation and interview on 12/16/2025 at approximately 11:05 AM a staff member was requested to shut oxygen to OR #2, and did not know were the valve to shut off oxygen was located. Surgery Department Director agreed that staff member did noot know the location of the shut off valve. The finding was verified by the Safety Officer and Engineering Director”