Centro Medico Del Noreste

“CONTRACTED SERVICES CFR(s): 482.12(e) The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 51782 Based on the review of documents and the interview with the Therapy Department Supervisor (employee #17), it was determined that the facility failed to ensure the credentials files (CF) for contracted services were updated for 5 out of 12 respiratory therapy credentials. (CF#1, 2, 6, 7 and 12) Findings include: 1. The facility has respiratory therapy under contracted services. During review of twelve personnel credential files with Therapy Supervisor performed on 07/16/2025 from 1:00 PM through 2:00 PM provided evidence of the following: a. One out of twelve credential files failed to show updated evidence of the Health Certificate (C.F #1). b. Four out of twelve credential files failed to show updated evidence of the chickenpox vaccine titers (C.F #1, C.F #2, C.F #6, C.F #12). c. One out of twelve credential files failed to show updated evidence of the annual evaluation (C.F. # 7). d. One out of twelve credential file failed to show updated evidence of the competency document (C.F. #7). e. The facility failed to ensure that contracted professional staff comply with requirements.”

“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: 47632 Based on records reviewed (RR) and interviews conducted with six patients on 07/17/2025, it was determined that the facility failed to ensure that the hospital inform each patient, or when appropriate, the patient’s representative, of the patient’s right, in advance of furnishing or discontinuing patient care for 3 out of 6 records reviewed (RR#11, 48 and 49). Findings include: Admission Supervisor (employee #19) provided the last update facility policy update on 05/2025, Derecho de Paciente: Patients Rights Livanta on 07/17/2025 at 11:43AM. The policy states on page 3: 6. A new “Important Message from Medicare” sheet should be provided as a follow-up and reminder of the right to appeal the discharge. 7. The follow-up sheet should be provided when it is anticipated.8. If the likelihood of discharge cannot be determined, the letter should be delivered the same day and at least four hours should be given for the beneficiary to consider his or her appeal rights and Livanta to review his or her case. 1. During interviews conducted on July 17, 2025, from 1:15 p.m. to 2:45 p.m., with six randomly selected patients, three of the following patients: RR#11, #48, and #49. These patients indicated that they were discharged early that day and did not receive the letter “Important Message from Medicare About Your Rights” within 48 hours prior to discharge. After the records reviewed of these patients the Important Message from Medicare About their rights was not in the record. The interview conducted with Admissions Supervisor (employee #19) on 07/15/2025 at 1:18 PM, stated that when the patient is admitted they are oriented of the Important Message from Medicare About Your Rights letter, they sign, and a copy is given to the patient to read their rights while they are in the hospital. When the patient is discharged, they are oriented and given the letter again to sign.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 51782 Based on records reviewed (R.R), advance directive policy and procedure, it was determined that the facility failed to ensure that patients or their representatives formulate advance directive and comply with these directives related to lack of physician order and justification for the consent of Do Not Intubate (DNI) and advance directive orientation for 4 out of 15 records reviewed of patient with Do Not Resuscitate DNR and DNI (R.R #6, 8, 10, and 25 ). Findings include: 1. Facility policy provided by Supervisor of the Medicine One Department (employee #16) on 07/16/2025 at 9:40 AM was reviewed. Document # ENF-88 was reviwed on 02/2024, “Rol del Personal de Enfermería En El Cumplimiento De Los Derechos Del Paciente Cuando Firma DNR-DNI (DO NOT RESUCITATE OR DO NOT INTUBATE)”. Policy states in section #1(a) that all physician-generated orders must be dated, time-stamped, legibly marked, and signed by the ordering physician. Section #1(c) states that the physician must make a progress note in the patient’s record, and Section #1(d) states that the physician must document family counseling regarding their current decision. a. R.R #6 is an 84-year-old woman who was admitted on 07/14/2025, with a diagnosis of Acute Respiratory Failure, Unspecified Whether with Hypoxia. During the record review performed on 07/16/2025, at 10:00 A.M., revealed for consent not to intubate (DNI) and do not resuscitate (DNR), signed by a family member. However, no date or time was observed on the document, and no evidence was found related to physician order for DNI/DNR and physician initial and subsequent progress notes for that justify the DNI/DNR and family orientation of the DNI/DNR. b. R.R #8 is a 90-year-old female who was admitted on 06/11/2025, with a diagnosis of CVA (Cerebro Vascular Accident) ARF on MV (acute respiratory failure on mechanical ventilator), Bedridden, HTN (hypertension) and DM II (diabetes mellitus type II). During record review performed on 07/16/2025, at 10:40 A.M., revealed for consent DNI and DNR, signed by a family member. However, no date or time was observed on the document DNI. No evidence was found of the medical progress notes justifying the DNI and DNR on 06/25/2025, 06/26/2025, 06/27/2025, 07/02/2025, 07/03/2025, 07/05/2025, 07/06/2025, 07/08/2025, 07/11/2025, 07/12/2025, 07/13/2025, 07/14/2025 and 07/15/2025. c. R.R #10 is an 80-year-old woman who was admitted on July 10, 2025, with a diagnosis of Elevated White Blood Cells Count, Unspecified. During record review performed on 07/16/2025, at 9:31 A.M., revealed a medical order in the system dated July 12, 2025, at 7:42 P.M., for consent to DNI and DNR, signed by a family member. However, no date or time was observed on the document. No evidence was found of the medical progress notes justifying the DNI and DNR on July 13, 2025, July 14, 2025, and July 15, 2025. In an interview with the supervisor (employee #16), of the medicine 1 department on 07/16/2025 at 9:45 AM, she indicates that once the patient has the signed DNR or DNI consent, a green band is placed on the patient’s arm and the record is identified with the same color and that when shift handover is done on each shift patient by patient, visiting all the rooms, they notify which patient has signed consent. 20423 d. R.R #25 is a 91-year-old female who was admitted on 07/15/2025 to the emergency room (ER) with a diagnosis of Congestive Heart Failure (CHF), Fluids Overall with Anasarca, Effusion Pleural, Pleural Edema, and Cystitis. During the record reviewed performed on 07/16/2025 at 1:00 PM provide evidence that on patient has an Affidavit # 9598 date March 17, 2018, that refuses transfusion and attention to prolongation life. On 07/16/2025 at 9:3 AM the patient signed Do Not Intubate (DNI) and Do Not Resuscitate (DNR) consent. However, no evidence was found related to physician order for DNI and DNR. No evidence was found related to physician progress notes that justify the DNI and DNR and patient orientation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 20423 Based on four (4) medical records reviewed (R.R.) for restraint, review of restraint policy and procedure (P&Ps), review of Mandatory Nursing Activities, it was determined that facility failed to ensure that restraint be used when least restrictive intervention have been determined be ineffective to protect patient and staff, for 1 out of 4 patients in restraint. (RR #25). Findings include: The Patient Restraint policy and procedure was reviewed on 07/16/2025 at 1:10 PM. 1.R.R #25 is a 91-year-old female who was admitted on 07/15/2025 to the emergency room (ER) with a diagnosis of Congestive Heart Failure (CHF), Fluids Overall with Anasarca, Effusion Pleural, Pleural Edema, and Cystitis. During the record reviewed performed on 07/16/2025 at 1:00 PM provide evidence that nurse documented that the patient family refer that patient try to remove the Intravenous (IV) and that was aggressive with nursing personnel, patient be restrictive according to physician order. The family was oriented to notify any change in condition, refer understand. On 07/16/2025 at 4:14 AM the physician places physician order and writes Restraint of patient physician Order. On 07/16/2025 at 4:10 AM the nurse documented the clinic document 234 title RN-Restricted Patient and documented that patient was anxious, level of consciousness: aggressive, behavior: attempts to move intravenous lines and other tubes, aggressive. In the second re-assessment performed on 07/16/2025 at 6:10 AM the nurse documented the clinic document 234 title RN-Restricted Patient and documented that patient level of consciousness: confuse,, behavior: attempts to move intravenous lines and other tubes. No evidence was found documented to remove or discontinue the restraint. The physician failed to evaluate the patient to determine if it needed or not to continue the use of restraint. The next assessment for restraint was performed on 07/16/2025 at 11:42 AM. However, no evidence was found related to the less restrictive measure and when determined that was ineffective proceed to restrain the patient. The physician failed to write a complete restraint physician order that included purpose of the restriction, duration of the restriction, type of restriction, and parts to be restricted. The physician failed to document in the physician’s progress notes a justification and a face-to-face assessment previous to restraint. No evidence was found that the nurse activates the plan of care for physical restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient or others from harm. This Standard is not met as evidenced by: 20423 Based on four medical records reviewed (R.R.) for restraint, review of restraint policy and procedure (P&Ps), review of Mandatory Nursing Activities, it was determined that facility failed to ensure that restraint be used when least restrictive intervention have been determined be ineffective to protect patient and staff, for 1 out of 4 patients in restraint. (RR #25). Findings include: The Patient Restraint policy and procedure was reviewed on 07/16/2025 at 1:10 PM. and stated in the following items: #2. The physician or nursing professional who identifies a patient at risk of harming themselves, other patients, or hospital staff should initiate the following preventive process before deciding to restrain the patient: a. Assess physiological, environmental, and behavioral needs. b. Promote environmental alternatives and evaluate their effectiveness before restraining the patient. e. Continually assess levels of consciousness. g. Evaluate whether the condition can be resolved with sedative medications, therapy, or other means. #5. The medical order or progress note must include: a. Date b. Time c. Purpose of the restraint d. Length of restraint e. Type of restraint f. Body parts to be restrained g. Medications (if applicable) 1. R.R #25 is a 91-year-old female who was admitted on 07/15/2025 to the emergency room (ER) with a diagnosis of Congestive Heart Failure (CHF), Fluids Overall with Anasarca, Effusion Pleural, Pleural Edema, and Cystitis. During the record reviewed performed on 07/16/2025 at 1:00 PM provide evidence that nurse documented that the patient family refer that patient try to remove the Intravenous (IV) and that was aggressive with nursing personnel, patient be restrictive according to physician order. The family was oriented to notify any change in condition, refer understand. On 07/16/2025 at 4:14 AM the physician places a physician order and writes Restraint of patient physician Order. On 07/16/2025 at 4:10 AM the nurse documented the clinic document 234 title RN-Restricted Patient and documented that patient was anxious, level of consciousness: aggressive, behavior: attempts to move intravenous lines and other tubes, aggressive. However, no evidence was found related to the less restrictive measure and when determined that was ineffective proceed to restrain the patient.”

“PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT CFR(s): 482.13(g)(1) & (3)(i) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (1) With the exception of deaths described under paragraph (g)(2) of this section, the hospital must report the following information to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint used on the patient during this time.”Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.... (3) The staff must document in the patient’s medical record the date and time the death was: (i) Reported to CMS for deaths described in paragraph (g)(1) of this section; or .... This Standard is not met as evidenced by: 51782 Based on review of restraint policy and interviews, it was determined that the facility failed to ensure that hospitals must report deaths to CMS associated with the use of seclusion or restraint. Findings include: 1. Facility policy provided by Social Worker (employee #15) on 07/16/2025 at 2:07 PM was reviewed. Document # TS/EN-25 was revised on 02/2024, “RESTRICCIÓN DE PACIENTES”- Patient Restrain , stated on page 65 in section K that any death that occurs within 24 hours after the patient has been removed from a restriction must be reported to the administration and the risk management program immediately. a) During the review of the patient restraint facility policy, performed on 07/16/2025, at 2:07 PM, there was no mention that deaths associated with patients in restraints should be reported to CMS accordingly with State Operation Manual Appendix A (Rev. 220; Issued:04/19/24) TAG A 0213 s §482.13(g)(1) & (3)(i) the hospital must report the following information to CMS by telephone, facsimile, or electronically. In an interview with the Social Worker, (employee 15), performed on 07/16/2025, at 2:15 PM, she indicated that such a policy was not available to her and that she had not had any incidents involving deaths to report. In an interview with the Director of Institutional Programs (employee #9), she indicated that she did not have a policy for reporting deaths due to restraints, but that she was aware that if such cases occurred, they should be reported to CMS and designated as sentinel events.”

“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: 17959 Based on the review of eighteen medical staff credential files (CF) perform on 7/15/2025 at 10:00 AM with the Human Resources (employee #8), it was determined that the facility failed to comply with federal and state local law related to Health Certificate and updated Cardiorespiratory certification (CPR) and ACLS for 3 out of 18 Physician (MD) Credential Files (C.F.) reviewed (C.F. MD#3, MD#4 and MD#17). Findings include: 1. During the review of eighteen medical staff credential files on 07/15/2025 at 10:00 AM with the Medical Staff Clerk (employee #20), the following was found: a. One out of eighteen medical staff’s credential files did not have evidence of their Health Certificate. (CF #3 expired on 06/22/2025) b. One out of eighteen medical staff’s credential files did not have evidence of their updated cardiorespiratory certification (CPR). (CF #4). c. One out of eighteen medical staff’s credential files did not have evidence of their updated ACLS certification expired on 06/2025. (CF #17).”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 47632 Based on forty-nine closed and active clinical records reviewed (RR) from 07/15/2025 to 07/17/2025, it was determined that the facility failed to ensure that all patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedure, 4 out of 49 Records Review (RR#13, 14, 15, and 23). Findings include: 1. RR# 13 is a 77-year-old female admitted to the facility on 06/12/2025 with Metabolic Acidosis. During the observation made to the clinical record with the Supervisor Department of Medicine I (employee #16) on 07/15/2025 at 10:45 AM, in the progress note on 07/13/2025 10:05 PM the respiratory therapy staff omitted his signature, date and time of order taking. 2. RR# 14 is a 60-year-old male admitted to the center on 07/14/2025 with viral pneumonia. During a review of his medical history by the supervisor of the Department of Medicine I (employee no. 16) on 07/15/2025 at 11:15 AM., he was prescribed Xoponex inhalation 1.25 milligrams (mg)/3 milliliters (ml), one ampoule every six hours, and Atrovent 0.02% inhalation, one ampoule every six hours, on 07/14/2025 at 7:00 p.m. No notes were found regarding the progress of respiratory therapy treatments administered by staff. 3. RR# 15 is a 69-year-old female admitted to the facility on 07/14/2025 with Respiratory distress. During the observation made to the clinical record with the Respiratory Therapy Supervisor (employee #16) on 07/15/2025 at 10:06 AM, in the progress note on 07/14/2025 6:51 PM and 3:00 AM the respiratory therapy staff omitted his signature, date and time of order taking. The facility failed to ensure date, timed, and appropriately authenticated by the person who is responsible for ordering, providing or evaluating the services provided. 20423 4. RR#23 is an 23-year-old female visit the emergency room on 07/15/2025 at 1:23 PM Reactive posterior Cervical Lymph Node. During the record review performed on 07/16/2025 at 10:00 AM provide evidence that the patient was evaluate and discharge home on 7/15/2025 at 9:49 AM, however no evidence was found that the nurse takes the vital sign before the discharge.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 47384 Based on observation tour of the facility and interviews from 07/15/2025 through 07/17/2025 between 8:30 AM to 3:30 PM, it was determined that the facility failed to ensure that the condition of the physical plant and the overall hospital environment is maintained in such a manner that the safety and well-being of patients as well as for employees and visitors. Findings include: 1. On 07/15/2025 at approximately 9:20 AM the area of the regular trash containers and biomedical waste was observed. This area is open and unrestricted for access by staff and visitors. The container was observed with its hatches open (without locks), allowing free access to unauthorized individuals. 2. On 07/16/2025 at approximately 10:30 AM during observation of Medicine Area 1 and Medicine Area 2 it was found that Bio Bazard and dirty linen rooms were unlocked and gave free access to personnel or unauthorized persons.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47384 Based on tests to equipment, interviews and observations made during the survey for Life Safety from fire with a facility Engineering Director (employee #3) and the Compliance Director (employee#1), 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 07/15/2025 through 07/17/2025 from 8:30 AM till 3:30 PM with the facility Engineering Director (employee #3) and Compliance Director (employee #1); for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS2567 form (K0225, K0347, K0353, K0908, K0909, K0914, K0916 and K0918).”

“FACILITIES CFR(s): 482.41(c) (d) Standard: Facilities. The hospital must maintain adequate facilities for its services. This Standard is not met as evidenced by: 51637 Based on observations and interview during the observational tour with the infection control officer ( employee# 7) on 07/15/25 at the hospital, it was determined that the facility failed to maintain adequate facilities for its services. Findings include: 1. At 9:33 AM in the Emergency Room isolation room area the bathroom sink was not turning on the faucet to turn on the hot water. 2. At 9:41 AM the intensive care area was checked and only 1 sink had the hot water faucet open, this being the one in the staff lounge. 3. Between 11:45 AM and 12:30 PM two inpatients on the Medicine 1 floor were interviewed and verbalized “the water is cold like the freezer”. 4. During the review of patient web complaints conducted on 07/15/2025 at 2:30 PM several patients were observed expressing no hot water during their hospital stay. In an interview conducted on 7/15/2025 at 2:45PM the infection control officer (employee #7) states that she was reviewing all the policy to make sure they comply with CDC requierements. 5. The facility failed to provide a policy for the use of hot water in patients areas. According to the Guidelines for Environmental Infection Control in Health-Care Facilities from 2003 updated on 2019, the facility must have hot water distribution systems serving patient-care areas operated under constant recirculation to provide continuous hot water at each outlet.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 51637 Based on observation tour of the facility and interviews on 07/15/2025 between 9:00 AM to 3:30 PM, it was determined that the facility failed to ensure that technological equipment, medical supplies and medical equipment must be maintained acceptable level of safety and quality. Findings include: 1. On 07/15/2025 at 9:17 AM a tour of the morgue area was made accompanied by the infection control program coordinator (employee #7) and the following was observed: a. In the anteroom of the morgue is the data server room which was observed with humidity and water filtration from the ceiling area. b. No smoke alarm or water sprinkler was observed in the server room. c. There was no thermometer available to measure temperature and humidity, however, the temperature of the morgue, which is measured daily, is maintained between 38 to 40 degrees (º) Fahrenheit (F) 2. During the tour conducted on 07/15/2025 at 3:06 PM in the supply storage where medical surgical products such as: IV solutions injections, IV lines, needles, alcohol preps and other materials are stored, an area of the ceiling was observed with the treatment or paint completely peeling off due to water filtration and humidity in that area. This deficiency was corrected on site prior to the completion of the inspection on 07/17/2025. According to the Guidelines for Design and Construction of Health Care Facilities FGI 2010 edition page 79, the technology equipment center (TEC) must be a sufficiently sized, environmentally controlled, power conditioned, fire protected, secure space with limited access that is located strategically to avoid any floodplain or other known hazard and the temperature and humidity in the technology distribution rooms (TDR) shall be controlled to an operating range of 64 to 75 degrees F (18 to 24 degrees C) with 30 to 55 percent relative humidity. 47384 3. During observation of the Radiology Department on 07/16/2025 approximately at 1:56 PM, it was observed that the entrance door to the Densitometry area did not have the glass completely sealed. The glass had an uncovered space which does not provide the required protection for a detailed area such as “Radiation Risk”. 47632 Infection Control Coordination (employee #7) provided the last update of the facility policy on 2024, Registro de Temperatura y Humedad on 07/17/2025 at 1:03PM. The policy states on page 2: 2. If there is a failure, the physical plant is contacted, and the log is recorded. The log sheet has a few spaces to record the follow-up. 3. if not in compliance, notify the physical plant department of follow-up and notify the infection control program and the engineer. 4. Follow-up actions are evidenced in writing documented by date, signature and comments. 4. During the observations made with the respiratory therapy supervisor on 07/15/2025 at 9:10 AM, it was observed that in the temperature and humidity log of the Clean Ventilator Room in the months of January, February, March, April, May, June, and July the Humidity was outside the accepted ranges. No corrective actions were found on the log sheet during those months. During the interview with the respiratory therapy supervisor, she stated that she had already notified the physical plant staff that the humidity in the clean ventilator room was out of range. She was asked for evidence of the notifications made and indicated that the notifications were verbal.”

“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: 15884 Based on an infection control observational tour, on 07/15/25 and from 9:00 AM through 11:30 AM, it was determined that the facility fails to implement methods for preventing and control the transmission of infections, including maintaining clean and sanitary environment within the hospital. This deficient practice has the potential to affect 54 out of 54 admitted patients. Findings include: 1Facility failed to promote a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections and comply with established requirements by Center for Disease Control and Prevention. The following findings were identified on 07/15/25 and from 9:00 AM through 11:30 AM during observational tour on medicine ward 1: While performing the infection control observational tour with the infection control officer (employee #7), it was identified on the second floor where dirty linen (contaminated) linen is stored that there is no available hand washing facilities readily available to workers and room did not have negative air pressure relative to the hospital clean areas. Not acording to CDC infectioon control guidance: http://www.cdc.,gov/infectioncontrol/guidelines/environmental/background/laundry.html Guidelines for Environmental Infection Control in Health-Care Facilities (2003)Background G. Laundry and Bedding. 51782 Policy and procedure related to terminal cleanings, last revision Feb 2024, was review with the infection control officer (employee #7) on 07/16/2025 at 10:04 AM 2. Facility failed to perform an isolation room complete disinfection according with Guidelines for Environmental Infection Control in Health-Care Facilities (2003) accordingly with the following findings: 3. While performing observation tour performed on 07/15/2025 at 2:43 PM of the isolation room without a patient, the mattress was observed to be tilted sideways without a sheet, at a 45-degree angle. However, belongings (shoes) were observed in the room, and (clothing) was seen on the floor in the bathroom. In an interview with the supervisor of the medicine 1 department, (employee #16) on 07/15/2025 at 2:50 PM indicated that upon seeing the mattress in that position, the terminal cleaning was finished. When asked, the environmental services staff stated that they only performed terminal cleaning of the bed. 47384 4. During observation of the facility, 3 eye wash stations were observed without dust covers, had water hardness marks indicative of lack of cleaning and did not have signed inspection cards. Facility’s “Programa de Manejo de Agua” states that this equipment must be inspected at least weekly. 17959 5. During the Infection Control tour by the Medical Record Department on 07/15/2025 at 8:55 AM with the Information Management Officer (employee #22) the following was observed: a. On 07/15/2025 at 8:55 AM a strong odor of humidity and dust was detected inside the medical record room. b. Floor and edges of the medical record room were observed porous, dirty tiles with dark spots and mold on the edges of the tiles. c. Inside of the Medical Record room, all the shelves were observed with dust on the tablets and accumulation of abundant dark dust on the floor behind the shelves. d. Walls and edges were observed with dust, dark spots and mold on the edges. e. Gap between the shelves on the right side and the one on the front wall, there was an accumulation of dust and rubber base detached from the column. f. In the bases of the metal shelves, pieces of cardboard were observed which are used to reinforce the unevenness of the floor; the pieces of cardboard were observed deteriorated and with dust. g. On the left side, between the first shelf and the second shelf in front of desk number eight, a column was a loose plastic cover with cable exposed was observed.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 51629 Based on interviews with the Discharge Planning coordinator (employee # 15), document review and six record review (RR) performed on 07/17/2025 at 10:35 AM, it was identified that the facility failed to implement a discharge planning process at an early stage of hospitalization for all patients. This deficient practice was identified in 3 out of 6 cases reviewed (RR # 4, RR # 9 and RR # 10). Findings include: The policy named: “Proceso de Planificación de alta” Discharge Planning Process (PA/TS-002, 2/2024 revision) was discussed and reviewed with the Discharge Planning Coordinator on 07/17/2025 at 10:35 AM. The facility policy states that a discharge planning assessment must be performed 24 hours after admission, with the exceptions of holidays. In the latter case, the assessment can be done on the next working day. During interview with the Discharge Planning coordinator (employee # 15), she stated that to any patient that complies with the approved criteria (65 years old or more, medicare patients, staff or physician referral, patient or family member’s request and patients without medical insurance), the discharge planning assessment must comply with the mentioned time frame. During the interview with the Discharge Planning coordinator (employee # 15), she stated that is the sole resource, acting both as a social worker and as the hospital discharge planning coordinator. 1. RR # 4 is a 52 - year - old male who was admitted on 07/05/2025 (Saturday) with a diagnosis of Advance Cirrhosis and End Stage Chronic Liver Disease. The initial discharge planning assessment was done on 07/08/2025 (Tuesday). 2. RR # 9 is a 91 - year - old female who was admitted on 07/11/2025 (Friday) with a diagnosis of Sepsis, Infected Sacral Ulcer, Acute Respiratory Failure and Alzheimer Disease. The initial discharge planning assessment was done on 07/14/2025 (Monday). 3. RR # 10 is a 80 - year - old female was admitted on 07/10/2025 (Thursday) with a diagnosis of Alzheimer Disease, Anemia and Hypertension. The initial discharge planning assessment was done on 07/14/2025 (Monday). 4. The facility failed to implement a discharge planning process at an early stage of hospitalization for all patients.”

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 07/16/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include revisions to their emergency preparedness plans, Emerging Infectious diseases are a potential threat which can impact the operations and continuity of care within a healthcare setting. Findings include: During the review of the facilities Emergency Preparedness Program with the facility Compliance Director (employee #4), it was noted that the facility failed to include emerging infectious diseases ( Influenza, Ebola, Zika, etc.) in the Emergency Plan.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 07/16/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures to track the location of on-duty staff and sheltered patients in the facility’s care during and an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the facility Compliance Director (employee #4), it was noted that the EP failed to have written procedures to document the specific name and location of the receiving facility or other location.”

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 07/16/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide means to shelter in place for patients, staff and volunteers who remain in the facility. Findings include: During the review of the facilities Emergency Preparedness Program with the facility Compliance Director (employee #4), it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the hospital during and after an emergency. The Compliance Officer indicated that the staff is aware of where the shelter in place area is, but no procedures were found written in the plan.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 07/16/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the facility Compliance Director (employee #4), 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 §485.15(b)(6). Compliance Director (employee #4), stated that facility is in communication with Medical Reserve Corps to facilitate the availability of volunteers and their credentialization.”

“Emergency Officials Contact Information CFR(s): §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 07/16/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain updated contact information for the following: Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance. Findings include: During the review of the facilities Emergency Preparedness Program with the facility Compliance Director (employee #4), it was noted that the facility failed to provide evidence of the Emergency Preparedness Communication Plan that included updated contact information for Federal, State, tribal, regional or local emergency preparedness staff and other sources of assistance. However the facility has contacts of local and state agencies, but not contacts from federal agencies.”

“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 upon an Emergency Preparedness Program (EPP) survey performed on 07/16/2025 at 1:00 PM through 3:30 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain a means of providing information about the facility’s occupancy, needs, and its ability to provide assistance during a emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the facility Compliance Director (employee # 4), 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, or designee. The facility recognizes that through the Health Services Coalition is the mechanism to provide information to the operations centers of the State Health Department and for the State Emergency Operations Center; no written procedure was found.”

“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 upon an Initial Life Safety Code (LSC) survey performed from 07/15/2025 through 07/17/2025, to evaluate LSC provisions, it was determined that the facility failed to comply with NFPA 101 7.2. Findings include: During visual observation of the facility’s interior stairway with the Compliance Director (employee #1) and Engineering Director (employee #3) on 07/15/2025 it was noted that the stairway did not provide special signage including the use of Braille within the enclosure at each floor landing. The finding was verified by the Director of Engineering and Compliance Director at the time of the observation.”

“Smoke Detection CFR(s): NFPA 101 Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2 This Standard is not met as evidenced by: 47384 Based on observation and interview the facility failed to maintain an automatic smoke detection systems as required on NFPA 72 and NFPA 75. Findings include: During visual observation of the facilities with the Compliance Director (employee #1) and Engineering Director (employee #3) on 07/15/2025, it was noted that no smoke detector was observed in the server room in the anteroom of the morgue data server room.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 47384 Based on observation and interview the facility failed to maintain an automatic sprinkler and standpipe systems that are inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Findings include: During visual observation of the facilities with the Compliance Director (employee #1) and Engineering Director (employee #3) on 07/15/2025, it was noted that 12 out of 30 sprinkler heads located in the ER area were loaded. Excessive dust in sprinklers can cause a malfunction in the moment of system activation. The finding was verified by the Director of Engineering and Compliance Director at the time of the observation.”

“Gas and Vacuum Piped Systems - Inspection and CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Inspection and Testing Operations The gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. Records of the inspections and testing are maintained as required. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observation and interview the facility failed to ensure that the gas and vacuum systems are inspected and tested as part of a maintenance program and include the required elements. 5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) Findings include: Observation and interview on 07/15/2025 at approximately 10:29 AM it was noted that medical gases emergency shut off valves on the Radiology Department, ER, Intensive Care Unit and Medicine 1 and Medicine 2 area were last inspected on May 2024 by proof of stamp in valves. The finding was verified by the Director of Engineering and Compliance Director at the time of the observation.”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observation and interview the facility failed to identify shutoff valves of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. . 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99). Findings include: Observation and interview on 07/15/2025 at approximately 10:29 AM it was noted that medical gases emergency shut off valves on Medicine 1 and Medicine 2 were not properly labeled as required by NFPA 99. The finding was verified by the Director of Engineering and Compliance Director at the time of the observation.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observation, document review and interview, the facility did not ensure that records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. Findings include: 1. At approximately 10:40 AM during observation of the Laboratory Department int was notice that three (3) breaker boxes had experied electrical inspection. Due date was 03/2025. The finding was verified by the Director of Engineering at the time of the observation.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observation, document review and interview, the facility did not ensure that a remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. Findings include: 1. At approximately 8:40 AM during observation of the basement area an inoperable generator remote annunciator was observed, Director of Engineering stated that none of the two (2) generator supplying backup power to the facility have remote annunciators. During survey facility obtained quotations for the equipment. The finding was verified by the Director of Engineering at the time of the observation.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 47384 Based on document review and interview, the facility did not ensure documentation that generators supply service within ten seconds in accordance with the requirements of NFPA 99, 2012 Edition Section 6 and NFPA 110. Findings include: 1. At approximately 11:50 AM document review and interview of the generator Test logs were reviewed and did not record generator transfer times. The finding was verified by the Director of Engineering at the time of the observation.”