Hospital Metropolitano Psiquiatrico De Cabo Rojo

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 47384 Based on an recertification survey and observations performed on on 04/21/26 at from 11:30 am till 2:55 pm, it was determined that the facility failed to maintain a safe and good sanitary environment in the Facility which makes this condition 42 CFR §482.41 Condition of Participation Physical Environment “Not Met” (Cross reference Tags A619, A701, A 750).”

“ORGAN, TISSUE, EYE PROCUREMENT CFR(s): 482.45 Organ, Tissue and Eye Procurement This Condition is not met as evidenced by: 51829 Based on the hospital visit, it was found that the facilities did not guarantee compliance with the specific requirements for obtaining organs, tissues and eyes: it does not have policies and protocols, it does not have agreements with Organ Procurement Organization (OPO) , it does not have quality indicators, it does not have agreements for the eye and tissue bank, and since it does not have a contract with OPO it does not ensure that the family is informed about the donation. Wich makes this condition Not Met 42 CFR §482.45 Condition of participation: organ, tissue and eye procurement ( Cross reference TAGS A885, A886, A887, and A888). .”

“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: 51637 Based on the review of personnel credential files (CF) and State Law License regulations requirements, it was determined that the facility failed to updated personnel credential files related to professional staff comply with the Hepatitis and Influenza vaccine and background check requirements. Findings include: 1. During the credential files review of food and dietary services (D.S.C.F.) conducted on 04/22/2026 from 10:50AM to 11:10AM, the following was found: a. Two out of two credential files failed to show updated evidence of the background check. (D.S.C.F. #1 and #2) b. One out of two credential files had no evidence of a recent Hepatitis B vaccine administration or positive titers. (D.S.C.F. #2) c. One out of two credential files had no evidence of a recent Influenza vaccine administration or a formal reject. (D.S.C.F. #2). 51782 2. During review of two personal of social work credential files (S.W.C.F), with the Human Resources Coordinator (employee #11) performed on 04/22/2025 at 11:40 AM till 12:10 PM provided evidence of the following: a) One out of two (S.W.C.F), failed to show updated evidence of influenza vaccine or the exoneration form for influenza vaccine, (S.W.C.F #2). b) One out of two (S.W.C.F), it was observed that the last dose of the hepatitis b vaccine was administered in 1987, and no hepatitis b titers were found. (S.W.C.F #2). c) One out of two (S.W.C.F), failed to show updated evidence of Law 300, background check (S.W.C.F #2). 51629 3. During review of seven nurse credential files (N.C.F) and one psychologist (P.C.F.) performed on 4/22/2026 from 10:00 AM till 12:00 PM the following was found: a. Four out of seven (N.C.F) and one out of one (P.C.F.) failed to show signing and dating in the job description documents (C.F. # 1, #3, #4, #6, #8). This finding does not comply with regulation 9184 of Law 101 of June 20, 1965: Regulations of the Secretary of Health for the construction, operation, maintenance and licensing of hospitals in P.R. Article 8.04 - Credentialing. b. Two out of seven (N.C.F) and one out of one (P.C.F.) failed to show evidence of chickenpox vaccine administration (C.F. # 4, # 8). This finding does not comply with regulation 9184 of Law 101 of June 20, 1965: Regulations of the Secretary of Health for the construction, operation, maintenance and licensing of hospitals in P.R. Article 8.08 - Employee health program.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 20423 Based on thirty-seven (37) record reviewed (R.R), review of policy and procedure and interview, it was determined that the facility failed to inform to each Medicare recipients of the “Important Message from Medicare” (IM) at the admission and two days before discharge to execute their rights to appeal facility’s discharge, for 2 out of 37 records reviewed. (RR #33 and #34). Findings include: 1. During the review of Administrative policy and procedure Manual on 04/21/2026 at 9:30 am with the institutional Program Director employee #2, it was found that the facility did not have a policy and procedure related to the notification to the patient or legal representative about patient rights to appeal discharge were reviewed the Important Message from Medicare (IM). 51782 2. RR #33 is a 67-year-old female Medicare beneficiary who was admitted on 01/14/2026 with a diagnosis of Schizophrenia. The patient was discharged home on 01/24/2026. During record reviewed on 04/22/2026 at 10:00 AM was revealed that the Important Message from Medicare was not provided two days prior to discharge. 3. RR #34 is a male Medicare beneficiary who was admitted on 03/15/2026 with a diagnosis of Impulsive Disorder, Dementia and Mayor Depression. The patient was discharged home on 03/20/2026. During record reviewed on 04/22/2026 at 10:30 AM was revealed that the Important Message from Medicare was not provided upon admission and not provided two days prior to discharge. During an interview on 04/22/2026, at 2:24 PM with the admissions officers (employees #13 and #14), both confirmed that the Medicare Important Message document is explained to and given to the patient or family member only upon admission, but not two days prior to discharge. The surveyor requested the policy or procedure related to the Important Message, which was not provided during the survey exit. 51629 4. During interview with the Discharge Planning coordinator (employee # 12) performed on 04/22/2026 at 11:00 AM, she stated that they do not provide the Medicare important message in advance 48 hours previous to discharge.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 20423 Based on the review of the facility Administrative Manual, review of admission package orientation, it was determined that the facility failed to establish a process for prompt resolution of patient grievances and that it must inform each patient whom to contact to file a grievance. Findings include: During the review of the administrative Manual and the review of admission package orientation on 04/21/2026 at 9:30 am, it was found that the facility has Policy: The Hospital is committed to handling all service complaints and grievances seriously and confidentially. Policy Complaint Handling, and the patient Grievance process orientation that includes whom to contact to file a grievance (complaint) and the phone, and address for filling a grievance with State Agency was requested and did not provided to the patient an updated state and federal Hot line telephone number, the state agency address and the state agency email to perform an grievance., as follows: Puerto Rico Department of Health: Secretaria para la Regulación de la Salud Pública (SARSP) “Secretary for the Regulation of Public Health” Law 101: 787-273-8488, State Agency Medicare: 787-273-8487, Federal Medicare Hot line: 1-800-633-4227 Email: sarfsquerellas@salud.pr.gov Adress: Ave. Ponce de León Parda 22 San Juan, PR 00909”

“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: 20423 Based on observation of ward A and Ward B, it was determined that the facility failed to ensure that patients receive care in a safe, sanitary, and comfortable environment setting. (Cross Reference TAG A0700, TAG A0701 and TAG A0750). Findings include: During the observation tour performed to the Ward A and Ward B with the infection Control officer employee #9, it was found that the facility did not assure that the environment setting has a positive visual impression to emotionally patients.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 15884 Based on review of quality assurance activities with the Quality Assessment and Performance Improvement officer (employee #2), it was identified that the facility failed to include contracted services in the Quality Assessment and Performance Improvement (QAPI) program. Findings include: 1. During the review of the facility’s hospital-wide quality assurance activities master plan natural year 2026 with the QAPI officer (employee #2) on 04/21/2026 at 1:50 pm it was identified that contracted services were not included as part of services to be submitted as quality indicators data in order to evaluate the performance of the services. a. Housekeeping, Laundry, Nutritional and Diet Department, Laboratory, Biohazard and Regular Waste, Ambulance and Acute Hospital are contracted services that are not submitting data collected based on indicators to track performance of the service. b. During interview on 04/21/2026 at 2:15 pm with the QAPI officer (employee #2) stated that this facility Housekeeping, Laundry, Nutritional and Diet Department, Laboratory, Biohazard and Regular Waste, Ambulance and Acute Hospital are services furnished under contract or arrangement and are not included as part of year 2026 facility’s hospital-wide quality assurance plan. c. Hospital’s governing body failed to ensure that the program reflects the complexity of the hospital’s organization and services; it involves all hospital departments and services. 51629 2. During interview with the Discharge Planning coordinator (employee # 12) and document review performed on 04/22/2026 at 11:00 AM, she stated that they maintain audits and monitoring through a table called “Auditoría de Expedientes” Records Audit, which records patients per month, indicating whether the file contains the required forms, but does not specify the threshold or the percentage of compliance for the evaluated month. Furthermore, no analysis of the data, trends, or improvement actions was provided. The facility did not maintain and demonstrate evidence of its quality assessment and performance improvement program (QAPI) for the Discharge Planning Program.”

“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: 47632 Based on personnel files reviewed and staff interview, it was determined that the facility failed to ensure that medical staff personnel maintained current and complete credentialing, immunization, certification, and background screening (LeyF 300) requirements in accordance with facility policy and applicable state regulation, credentials files (CF) in 4 out of 8 ( CF #2, CF #4, CF #7 and CF #8). Findings include: On 04/22/2026 at 1:43 PM, a review of medical staff personnel CF was conducted. The review revealed the following was found: 1. CF #2 the personnel file lacked: Current influenza vaccination or declination documentation. The last documented influenza vaccine was administered on March 10, 2025, with no evidence of update for the current influenza season. 2. CF #4 the personnel file lacked: Current Cardiopulmonary Resuscitation (CPR) certification. The CPR certification expired in March 2025. 3. CF #7 the personnel file lacked: current influenza vaccination (last documented on September 29, 2023) and background Check (Ley 300). 4. CF #8 the personnel file lacked: hepatitis B vaccination documentation, current influenza vaccination, and background check in accordance with state Law, which expired on March 31, 2025. During an interview conducted on 04/22/2026 at 2:03 PM, the Operations Manager (employee #1) was asked to provide the missing credentialing documentation for the medical staff. The Operations Manager was unable to provide the requested documentation at the time of the survey. 5. The facility failed to ensure that the medical staff personnel maintained current and complete credentialing and health-related requirements in accordance with State Regulation No. 9184, date July 1, 2020, and facility’s policy.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 47632 Based on review of the Medical Staff Bylaws and staff interview, it was determined that the facility failed to ensure that the Medical Staff Bylaws included all required rules and regulations governing medical staff practices in accordance with applicable state laws and regulations. Findings include: 1. During review of the Medical Staff Bylaws conducted on 04/22/2026 at 1:40 PM, in the presence of the Medical Director (employee #8), it was determined that the Bylaws were incomplete. The review revealed that the Bylaw lacked policies, rules, and regulations addressing the following required areas: Do Not Intubate (DNI) orders. Autopsy procedures. Use of restraints. These elements are required to be addressed in accordance with State Regulation No. 9184, dated July 1, 2020. 2. During the interview, the Medical Director (employee #8) confirmed that the above-mentioned topics were not included in the Medical Staff Bylaws.”

“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 clinical records reviewed (RR) and staff interview, it was determined that the facility failed to ensure that medical records, including individualized treatment plans and supporting clinical documentation, were complete, accurate, and contained all required elements for 8 out of 37 records reviewed (RR #1, #2, #7, #11, # 14, #15, #16 and #18). Findings include: During a clinical record review conducted on 04/21/2026 through 04/22/2026 between 8:40 AM to 4:00 PM, the following deficiencies were identified: 1. RR #1 is a 33-year-old male admitted on 04/16/2026 with recurrent major depression. On 04/21/2026 at 1:33 PM, review of the record revealed: a. The individualized treatment plan lacked: Did not indicate the patient’s legal status (voluntary or involuntary). Level of treatment was not documented. Signature of recreational therapy staff was missing. 2. RR #2 is a 40 years-old male admitted on 04/19/2026 with schizophrenia. On 04/22/2026 at 10:49 AM, the following deficiencies were identified: a. The individualized treatment plan lacked: Did not indicate the patient’s legal status (voluntary or involuntary). Level of Treatment was not documented. Signature of recreational therapy staff was missing. Signature of the general physician was missing. b. The medical evaluation lacked: Psychiatrist’s signature, license, and date were missing. c. The nutritional assessment was not filled out by the physician. 3. RR#7 is a 43 years-old male admitted on 04/20/2026 with bipolar disorder. On 04/22/2026 at 9:26 AM, the following deficiencies were identified: a. The individualized treatment plan lacked: Did not indicate the patient’s legal status (voluntary or involuntary). Level of treatment was not documented. Signature of recreational therapy staff was missing. b. The suicide severity assessment form lacked: Patient name, medical record number, date of birth was missing. 4. RR #15 is a 68 years-old female admitted on 04/09/2026 with severe sycosis. On 04/22/2026 at 8:49 AM, the following deficiencies were identified: a. The individualized treatment plan lacked: Did not indicate the patient’s legal status (voluntary or involuntary). Level of Treatment was not documented. Signature of occupational therapy staff was missing. Signature of the nutritionist was missing. b. The admission order lacked: Date and time from the physician. 5. RR #18 is a 33 years-old male admitted on 02/05/2026 with severe sycosis. On 04/21/2026 at 1:47 PM, the following deficiencies were identified: a. The patient was transferred to Hospital B for CT scan of the head as ordered by the general physician. There was no transfer documentation in the medical record. There was no physician progress note indicating the clinical justification for CT scan. This was confirmed during interview with the Registered Nurse (employee #4), who verified that the transfer form was not available. 51629 6. RR# 16 is a 44 years-old female admitted on 04/19/2026 with a diagnosis of Bipolar Disorder. During record review performed on 04/21/26 at 9:52 AM, the following deficiency was identified: a. Individualized care plan not documented by the psychiatrist, case manager and recreational therapist. During interview with the Discharge Planning coordinator / Case manager supervisor (employee # 12) performed on 04/22/2026 at 11:00 AM, she stated that this document must be completed 24-48 hours after patient admission. b. Advance directives form, not signed nor dated. It does not specify which advance directive is submitting or accepting and which does not accept. c. Stabilization ward summary of evaluation form - documented only by physician on 04/20/2026 at 6:25 AM. 7. RR # 11 is a 49 years-old female admitted on 04/16/2026 with a diagnosis of Schizophrenia Unspecified. During record review performed on 04/21/26 at 1:30 PM, the following deficiency was identified: a. Individualized care plan not documented by the recreational therapist. 8. RR # 14 is a 48 years-old female admitted on 04/19/2026 with a diagnosis of Schizoaffective Disorder. During record review performed on 04/21/26 at 10:21 AM, the following deficiency was identified: a. Individualized care plan not documented by the recreational therapist. b. Medication reconciliation form not signed by physician. c. Advance directives form, signed by the patient on 04/19/26 but does not specify which advance directive is submitting or accepting and which does not accept. d. Nutritional assessment form - not documented.”

“CONTENT OF RECORD: ORDERS DATED & SIGNED CFR(s): 482.24(c)(2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 51629 Based on document review performed on 04/21/2026 at 1:30 PM, it was identified that the facility failed to ensure that all orders, including verbal orders, are dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient in 1 out of 37 records reviwed (RR) (RR #11) Findings include: 1. RR # 11 is a 49 years-old female admitted on 04/16/2026 with a diagnosis of Schizophrenia Unspecified. During record review performed on 04/21/26 at 1:30 PM, the following deficiency was identified: a. A telephone order taken by the registered nurse on 04/19/2026 at 3:00 AM. The physician ordered a medication administration of “APAP 1000 mg oral every 6 hours and STAT”. At the time of the record review, the order had not been countersigned. b. A telephone order taken by the registered nurse on 04/19/2026 at 3:50 AM. The physician ordered a medication administration of “Risperdal 1mg oral STAT”. At the time of the record review, the order had not been countersigned. c. The two medical order documents were only identified by the patient’s name. d. The facility policy named “Toma de órdenes médicas” (revision period not available) states that a telephone order must be countersign by the ordering physician in a time not exceeding 24 hours after it is prescribed. The facility failed to ensure that all orders are authenticated promptly by the ordering practitioner.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 47632 Based on clinical records reviewed (RR) and staff interview, it was determined that the facility failed to ensure that medical record entries were completed and accurately documented to reflect the patient’s condition, clinical justification, and ongoing monitoring of 1 out of 1 record reviewed (RR #18). Findings include: 1.PR #18 is a 33-year-old male admitted on 02/05/2026 with diagnosis of major depression and anxiety. Clinical record review was conducted on 04/21/2026 at 1:47 PM, it was revealed: The Patient was transferred to Hospital B for a computed tomography (CT) scan of the head as ordered by the general physician. However, the medical record lacked: a. A physician progress note documenting the clinical rationale/justification for ordering the CT scan. b. Documentation reflecting the patient clinical condition prior to transfer. c. Evidence of patient monitoring and reassessment related to change in condition that prompted the diagnostic test and transfer. d. A post-diagnostic physician progress notes documenting: The CT scan results The physician interpretation, and any changes in treatment plan or follow up care.”

“CONTROLLED DRUGS KEPT LOCKED CFR(s): 482.25(b)(2)(ii) Drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970 must be kept locked within a secure area. This Standard is not met as evidenced by: 51782 Based on policies reviewed, observations and interviews made in the Adult Behavioral Health Unit, on 04/21/2026 from 9:45 AM to 10:45 AM, it was determined that the facility failed to maintain controlled medication category IV in a secure area. Findings include: 1. During observations conducted in the Adult Behavioral Health Unit with Director of the Pharmacy Department (employee #10), the following were observed: a) On 04/21/2026 at 9:54 AM, in the medicine room, the controlled medication Ativan is found in the unlocked medicine refrigerator. During an interview with the Director of the Pharmacy Department (employee #10), stated that the refrigerator was replaced because the previous one had been damaged the day before, and that she is waiting for the maintenance staff to put the lock on the refrigerator.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 51637 Based on observations, interviews and documents review, it was determined that the facility failed to assure that the kitchen staff complies with the kitchen standards regarding the disinfection and temperature measurement of the water when washing the trays and utensils, hand washing and adequate condition of the equipment. The Guidelines for Environmental Infection Control in Health-Care Facilities from de CDC published on 2003 and updated in July 2019, stated that to infection prevention control in hospital kitchens they must have a minimum water temperature of 120 grades Fahrenheit. https://www.cdc.gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf Findings include: 1. During the kitchen tour performed on 04/21/2026 from 9:00am till 11:30 am accompanied by the kitchen supervisor (employee #6) the following was observed: a. The employee handwashing station was not working, and no alternative handwashing method was observed. No employee was observed using handwashing facilities at any time. b. The three-compartment sinks where kitchen utensils, food trays, and plates are washed do not have hot water for sanitizing. c. The shelves in the food refrigerator where food is stored are corroded and in poor condition.”

“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 an physical environment observational tour performed on 04/21/2026 through 04/22/2026, and interview after observational tour with the facility’s Operational Manager (employee #1) on 04/21/26 at from 11:30 am till 2:55 pm, it was determined that the facility failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients is assured. This is related with facility glass front entrance door broken, glass window located at side of the front entrance broken, air conditioners defective in the therapy area and the storage area, temperatures on the dining area and kitchen area did not reach cool levels, aisles electric receptacles without protective cover, cistern area with pumps showing some malfunction, courtyard exterior lights indicating some kind of malfunction, column between rooms with damage on the surface and paintwork damage, plinth unglued in the physical therapy area, water heaters in the mechanical room area were observed in poor condition and inoperative, peeling paint in patient room walls, and decorative paper areas, windows covered with green slimy texture dirt, bathroom shower with green stains, hard water stains and black stains, toilet screws covered in dark brown mold, cracked wall, shower wall with stains between the tiles, raised paint at window jamb, clean laundry room with ceiling tiles with damp stains, bed module with peeling paint, decorative window wallpaper torn and peeling, doors with peeling paint, the bathroom (shower) wall with crack wall, air conditioning vents with brown stains, bare walls and window with green mold and hole in the floor. All of which makes this condition “Not Met”. (Cross Reference TAG A 0750). Findings include: 1. On 04/21/2026 at approximately 9:00 AM, front entrance door was observed to be broken and covered with wood panels. 2. Two (2) air conditioners were found to be defective, one in the therapy area and one in the storage area. 3. On 04/21/2026 at approximately 9:46 AM, it was noticed that temperatures on the dining area and kitchen area did not reach cool levels. 4. On 04/21/2026 at approximately 9:46 AM, kitchen back door was found open due to hot temperatures, as explained by kitchen personnel it is kept open in order to get some ventilation. 5. On 04/22/2026 at approximately 10:40 AM, it was observed in aisles A and B that 7 out of 12 receptacles did not have a protective cover. 6. On 04/22/2026 at approximately 2:10 PM, it was observed in the cistern area that pump #1 was disassembled, and pump #2 was leaking, indicative of some malfunction. 7. On 04/21/2026 at approximately 10:19 AM, in the courtyard it was noticed that exterior lights with photocells were on indicating some kind of malfunction. 8. On 04/21/2026 at approximately 9:10 AM, It was observed that in the column between rooms 101 and 103 and between rooms 111 and 113 there was damage to the paintwork and damage to the surface. 9. On 04/21/2026 at approximately 11:15 AM, it was noticed that plinth were unglued in the Physical Therapy area. 10. Two water heaters in the mechanical room area were observed to be in poor condition and inoperative. 20423 The following findings were identified on 04/21/2026 from 10:50 AM through 12:00 AM during observational tour: 11. In Hallway A and B. a. At 11:00 am Room 121 peeling paint on top of the light switch, Windows with green stains and peeling decorative paper b In the bathroom the shower was observed with green stains, hard water stains and black stains and the toilet screws covered in dark brown mold. In all bathrooms. (Room 101 through 121). c. Room 120 windows with peeling decorative paper. d. Room 119 with peeling paint and bulky on the right wall and windows with peeling decorative paper. e. Room 118 Wall adjacent to the bathroom with peeling paint and cracked wall. f. Room 117 Shower wall with stains between the tiles, Window wall with raised paint. g. Clean Laundry Room was observed with acoustic with damp stain. h. Room 116 with peeling door, wall behind the sample chair with peeling paint. Floor with brown stains around the weight. Wall near the door with pilling paint. i. Room 115 with the wall near to the door with peeling paint. Bed module with peeling paint. Wall behind bed A with peeling paint. Decorative window wallpaper torn and peeling. j. Room 114 with Wall behind bed A with peeling paint, Bed module with peeling paint. k. Room 113, wall on the left side of the door with peeling paint, the bathroom (shower) wall with crack wall. The wall above the mirror with peeling paint. Bed module A, and B with peeling paint, Wall next to bed A with peeling paint l. Room 112, Window frame with brown stains, Bed module A, and B with peeling paint m. Room 111 wall below exit button with a hole, the bathroom (shower) wall with crack wall. Window wall with peeling paint, Bed module A, and B with peeling paint. n. Room 109 walls with peeling paint. o. Room 108 with window wall with peeling paint, air conditioning vent with brown stains. p. Room 107 with bulging painting on column next to the door, Wall next to bed A with peeling paint q. Room 106 with patients’ clothes and sheets on the floor. r. Room 105 with bare walls and window with green mold. s. Hallway wall between rooms 103 and 101 with peeling paint t. Room 103 with left side wall with raised and peeling paint, bare and written wooden table. u. Room 101 with wall adjoining the bathroom with peeling paint. v. In front of room 108 there is a hole in the floor. w. This does not allow for proper cleaning and disinfection. 15884 12. Facility’s Operational Manager (employee #1) was asked on 04/21/26 at from 11:30 am till 2:55 pm, about deplorable condition were the physical plant patient treatment and kitchen were found. This is what she report in relation with physical plant patient treatment and kitchen condition: a. She stated that this corporation buy this facility and begin to provide services on December 1, 2025 at midnight. She explain stated that there was only 1 patient that had been receiving treatment with former owner and refuse to be discharged or transferred during the transition. She stated that as soon as new owner realized the poor condition were the physical environment and utilities of the facility are they begin to plan the repairs and reconstruction. b. She stated that after perform an assessment of areas who require priorities to work on them first they identify that the first priority was to fix systems so that there is hot water available. This because in the building there are no hot water available for patients and in the kitchen. c. She stated that whatever way possible they want to work first with the hot water availability and as second priority with the building plumbing system who inlude showers, sinks toilets and water cistern. d. She explain they plan to replace the door and window broken at the entrance of the facility thast were broken by a patient. e. In the kitchen area they plan to fix the cooler. f. They plan to begin to provide maintenance on the kitchen hood were there is about 2 years since it was done. g. She stated that they need to fix systems so that there is hot water available on the kitchen. 13. Facility’ s’ Operational Manager (employee #1) was asked on 04/21/26 at 2:45 pm, in which financial phase there are the priorities that facility had for the physical environment and utilities that facility are going to fix, repair make functional again. This is what she report in relation with physical plant patient treatment and kitchen financial phase of the priorities that facility had identified to work with: a. She stated that the repairs are in the quotation phase, to ensure profitable, organized project. b. Facility’s Operational Manager (employee #1) was asked on 04/21/26 at 2:48 pm, if the new owners have a projection of time were the repairs and reconstruction will begin and finish and she state that facility did not had an projection of the time to begin and finish reconstructions. She stated it all depends on project execution. c. Facility’s Operational Manager (employee #1) was asked on 04/21/26 at 2:53 pm if facility owner had knowledge of the impact that could physical environment, structural decay and malfunction of facility utilities could had in the emotional status of patients who receive treatment for mental health conditions. She stated that facility owners best interest is to improve patient institutional environment who was decay and in poor condition by the former owner.”

“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: 20423 Based on an infection control observational tour, on 04/21/2026 10:50 AM through 12:00 PM, 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 35 out of 35 admitted patients. (Cross Reference TAG A 0701). Findings include: Facility 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 04/21/2026 from 10:50 AM through 12:00 AM during observational tour: 1. In the waiting Area: a. The man bathroom was observe stains on the floor and no hot water in the sink. b. Vinyl tiles with holes and cracks do not allow for proper cleaning and disinfection. c. Two (2) chairs with torn vinyl. d. Two (20 chairs with faded vinyl with black wear stains. 2. In the triage Area: a. Vinyl tiles with cracks do not allow for proper cleaning and disinfection. 3. In the Evaluation physician office; a. Examination table with torn vinyl. b. Sink faucets with hard water stains. c. Sphygmomanometer stand with yellow and black stains. d. Right side wall below the ear physical examination (otoscope) with bulky and puffy paint. e. Humidity odor. 4. In Hallway A and B. a. At 11:00 am Room 121 peeling paint on top of the light switch, Windows with green stains and peeling decorative paper b In the bathroom the shower was observed with green stains, hard water stains and black stains and the toilet screws covered in dark brown mold. In all bathrooms. (Room 101 through 121). c. Room 120 windows with peeling decorative paper. d. Room 119 with peeling paint and bulky on the right wall and windows with peeling decorative paper. e. Room 118 Wall adjacent to the bathroom with peeling paint and cracked wall. f. Room 117 Shower wall with stains between the tiles, Window wall with raised paint. g. Clean Laundry Room was observed with acoustic with damp stain. h. Room 116 with peeling door, wall behind the sample chair with peeling paint. Floor with brown stains around the weight. Wall near the door with pilling paint. i. Room 115 with the wall near to the door with peeling paint. Bed module with peeling paint. Wall behind bed A with peeling paint. Decorative window wallpaper torn and peeling. j. Room 114 with Wall behind bed A with peeling paint, Bed module with peeling paint. k. Room 113, wall on the left side of the door with peeling paint, the bathroom (shower) wall with crack wall. The wall above the mirror with peeling paint. Bed module A, and B with peeling paint, Wall next to bed A with peeling paint l. Room 112, Window frame with brown stains, Bed module A, and B with peeling paint m. Room 111 wall below exit button with a hole, the bathroom (shower) wall with crack wall. Window wall with peeling paint, Bed module A, and B with peeling paint. n. Room 109 walls with peeling paint. o. Room 108 with window wall with peeling paint, air conditioning vent with brown stains. p. Room 107 with bulging painting on column next to the door, Wall next to bed A with peeling paint q. Room 106 with patients’ clothes and sheets on the floor. r. Room 105 with bare walls and window with green mold. s. Hallway wall between rooms 103 and 101 with peeling paint t. Room 103 with left side wall with raised and peeling paint, bare and written wooden table. u. Room 101 with wall adjoining the bathroom with peeling paint. v. In front of room 108 there is a hole in the floor. w. This does not allow for proper cleaning and disinfection. 51829 5. Based on observations during the visit to the hospital it was found that the facilities did not ensure compliance with best practices for prevention, patient safety, and infection control to prevent and minimize infections. During a hospital visit on April 21, 2026, at 10:53 a.m., accompanied by a registered nurse (employee #4), interviews, observation, and a review were conducted. The following medical-surgical supplies, specifically expired endotracheal tubes of various sizes, were identified in the crash cart located in the room managment emergency . a. From 1998: 2 tubes of size 4, 1 tube of size 5, 2 tubes of size 5.5, 3 tubes of size 6, 2 tubes of size 7, 2 tubes of size 7.5, 2 tubes of size 8, 2 tubes of size 8.5, and 1 tube of size 9. b. From October 29, 2001: 3 tubes of size 5. c. It was noted that the crash cart is subject to policy review on each shift, is included in the daily assignment, and is verified by the pharmacy department. During an interview conducted on 4/21/2026 at 10:00 am with the professional nurse (employee #4), she stated that the packaging only has this date, and since it does not have an expiration date, it is assumed that it is still valid.”

“TRANSFER PROTOCOLS CFR(s): Effective July 1, 2025, the hospital must have written policies and procedures for transferring patients under its care (inclusive of inpatient services) to the appropriate level of care (including to another hospital) as needed to meet the needs of the patient. The hospital must also provide annual training to relevant staff regarding the hospital policies and procedures for transferring patients under its care. This Standard is not met as evidenced by: 47632 Based on clinical records reviewed (RR), it was determined that the facility failed to ensure the implementation of its policies and procedures related to patient transfer to other institutions. Findings include: 1. On 04/21/2026 at 1:47 PM, a clinical record review was conducted for RR #18 is a 33-year-old male admitted with diagnoses of major depression and anxiety. The review revealed that the patient was transferred to another institution for further diagnostic evaluation. However, the medical record lacked a completed patient transfer form, as required by the facility’s established policies and procedures. A review of the facility’s policy titled “Patient Transfer to Other Institutions” and “Patient Transfer Protocol” indicated that a transfer form must be completed and included in the patient’s medical record to ensure continuity of care and proper documentation of the transfer process. During the review, there was no evidence that the general physician completed the required transfer documentation in accordance with facility policy.”

“OPO AGREEMENT CFR(s): 482.45(a)(1) Incorporate an agreement with an OPO designated under part 486 of this chapter, under which it must notify, in a timely manner, the OPO or a third party designated by the OPO of individuals whose death is imminent or who have died in the hospital. The OPO determines medical suitability for organ donation and, in the absence of alternative arrangements by the hospital, the OPO determines medical suitability for tissue and eye donation, using the definition of potential tissue and eye donor and the notification protocol developed in consultation with the tissue and eye banks identified by the hospital for this purpose; This Standard is not met as evidenced by: 51829 Based on the hospital visit, it was found that the facilities did not guarantee compliance with the specific requirements for obtaining organs, tissues and eyes in relation to definitions, responsibilities and quality indicators. Findings include: 1. The hospital does not have a written agreement with an Organ Procurement Organization (OPO), designated in 42 CFR Part 486. This agreement must address at least the following: criteria for imminent death or death in the hospital, including the definition of imminent death, timely notification, and the OPO’s responsibility, among other things. 2. It lacks performance indicators because the donation program is required to be integrated into the hospital’s Quality Assurance Program (QAPI). In an interview conducted with the director of operations (employee # 1) on 4/22/2026 at 9:50 a.m., she confirms that they do not have a contract and proceeds to contact the Organization and receives guidance, where she delivers the part done by email.”

“TISSUE AND EYE BANK AGREEMENTS CFR(s): 482.45(a)(2) Incorporate an agreement with at least one tissue bank and at least one eye bank to cooperate in the retrieval, processing, preservation, storage and distribution of tissues and eyes, as may be appropriate to assure that all usable tissues and eyes are obtained from potential donors, insofar as such an agreement does not interfere with organ procurement; This Standard is not met as evidenced by: 51829 Based on the visit to the hospital, it was found that the facilities did not guarantee compliance with the specific requirements for obtaining tissues and eyes. Findings include: The hospital does not have an agreement with at least one tissue bank and eye bank to cooperate with the recovery, processing, preservation, storage, and distribution of tissues and eyes as appropriate.”

“INFORMED FAMILY CFR(s): 482.45(a)(3) Ensure, in collaboration with the designated OPO, that the family of each potential donor is informed of its options to donate organs, tissues, or eyes, or to decline to donate. This Standard is not met as evidenced by: 51829 Based on the hospital visit, it was found that the facilities did not guarantee compliance with the requirements for guidance on donation and the right to reuse. Findings include: The hospital does not have a contract with OPO, it cannot ensure that the family of the potential donor is properly informed of the options to donate organs, tissue or eyes, or to refuse donation.”

“Social Services CFR(s): Standard: Social Services There must be a director of social services who monitors and evaluates the quality and appropriateness of social services furnished. The services must be furnished in accordance with accepted standards of practice and established policies and procedures. This Standard is not met as evidenced by: 51782 Based on review of personal files and interviews, it was determined that the facility failed to ensure social services were directed by a staff member who was formally designated in writing the functions. Findings include: 1. During survey process, it was found that the social work supervisor performs functions corresponding to the Director of Social Work. However, a review of the file on 04/22/2026 at 11:45 AM, revealed no official written appointment to support this designation. In an interview with the Human Resources Coordinator (employee #11), on 04/22/2026 at 11:50 AM and with Social Servies Supervisor (employee #12) on 04/22/2026 at 1:25 PM both confirmed that she is responsible for overseeing social services, including staff supervision and program coordination. Despite performing these duties, no formal written designated was provided.”

“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 on an Emergency Preparedness Program (EPP) survey performed on 04/21/2026 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include revisions to their emergency preparedness plans, Emerging Infectious Deseases (EID’s) are a potential threat which can impact the operations and continuity of care within a healthcare setting and should be considered. Findings include: During the review of the facilities Emergency Preparedness Program with the Institutional Program Director (employee #2), it was noted that the facility failed to include emerging infectious diseases (Influenza, Ebola, Zika, etc.) in the Emergency Plan.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 04/21/2026 at 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings include: During the review of the facilities Emergency Preparedness Program with the Institutional Program Director (employee #2),on 04/21/2026 from 8:00 AM through 3:00 PM it was noted that the facility failed to include a documented facility and community based all hazard approach risk assessment.”

“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 upon an Emergency Preparedness Program (EPP) survey performed on 04/21/2026 at 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to have process for cooperation and collaboration with local, tribal, regional, State and Federal preparedness officials ’ effort to maintain an integrated response during s disaster or emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the Institutional Program Director (employee #2), 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 §416.54 (a)(1)-(2) of the Emergency Preparedness. No evidence of participation with the Regional Health Care Coalition was presented.”

“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 04/22/2026 from 8:00 AM through 3:00 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 Institutional Program Director (employee #2), 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 04/21/2026, 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 Institutional Program Director (employee #2), it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the facility during and after an emergency.”

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 04/21/2026 from 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to have policies and procedures describing the system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records. Findings include: During the review of the facilities Emergency Preparedness Program on 04/21/2026 it was noted that the EP failed to have written process for preserving patient information as required under §482.15(b)(5).”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 04/21/2026 at 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain policies and procedures related with the role of the facility under a waiver declared by the Secretary in accordance with section 1135 of the Act in the provision of care and treatment. Findings include: During the review of the Emergency Preparedness Program on 04/21/2026 it was noted that the EP failed to include policies and procedures which outline the facility’s role in the provision of care and treatment under section 1135 waivers during a declared public health emergency in alternate care sites as required under §482.15(b)(8).”

“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 upon an Emergency Preparedness Program (EPP) survey performed on 04/21/2026 at 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop primary / alternate means for communication with 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 Institutional Program Director (employee #2) on 04/21/2026, it was noted that the facility failed 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 §416.54(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 upon an Emergency Preparedness Program (EPP) survey performed on 04/21/2026 from 9:00 AM through 4:00 AM, to evaluate emergency preparedness requirements for recertification, 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 Institutional Program Director (employee #2), 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 an Emergency Preparedness Program (EPP) survey performed on 04/21/2026from 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to have means of providing information about the facility’s occupancy, needs, and its ability to aid during an emergency. Findings include: During the review of the facilities Emergency Preparedness Program with the Institutional Program Director (employee #2) on 04/21/2026, it was noted that the facility failed to have written procedures for providing information about the facility’s occupancy, needs, and its ability to aid, to the authority having jurisdiction, the Incident Command Center, or designee.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 47384 Based on an Emergency Preparedness Program (EPP) survey performed on 04/21/2026 form 8:00 AM through 3:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan. Findings include: During the review of the facilities Emergency Preparedness Program with Institutional Program Director (employee #2) , it was noted that the EP failed to develop and maintain an emergency preparedness training and testing program based on the facilities risk assessment.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 47384 Based on an Emergency Preparedness Program (EPP) survey performed on 01/28/2025 at 9:30 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. Findings include: During the review of the facilities Emergency Preparedness Program with the Institutional Program Director (employee # 2) , it was noted that the facility failed to provide documentation of training on emergency preparedness policies and procedures to all new and existing staff.”

“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 observation and interview, the facility failed to maintain means of egress in a manner that allows for free and unobstructed escape in the event of an emergency, in accordance with National Fire Protection Association Life Safety Code requirements. Findings include: During the survey, it was observed that two (2) egress gates were equipped with key-operated locking mechanisms. If locked this could prevent the free acces in a event. 1.One (1) gate was located along the egress path leading from the recreational courtyard, passing through the back kitchen hallway, and discharging to the exterior of the building. 2.One (1) gate was identified as the egress gate leading directly to the public sidewalk. Both gates were determined to be part of the required means of egress; however, the presence of key-operated locks (if locked) does not permit immediate egress without the use of a key, tool, or special knowledge, which is not compliant with Life Safety Code requirements. This condition has the potential to delay or prevent occupants from safely exiting the building during an emergency.”

“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 observation and interview, the facility failed to ensure that doors equipped with special locking arrangements, including those with electromagnetic locking devices, were installed and maintained to automatically release upon activation of the fire alarm or loss of power, in accordance with the National Fire Protection Association Life Safety Code requirements. Findings include: 1. During the survey, it was observed that a smoke barrier door separating two (2) smoke compartments was equipped with a magnetic hold-open/release device that had been rendered inoperable (disabled). The magnetic device did not function as intended to automatically release the door upon activation of the fire alarm system or other initiating device, preventing the door from closing to maintain the integrity of the smoke barrier. Smoke barrier doors are required to automatically close to restrict the movement of smoke between compartments during a fire event. The inoperable magnetic release device compromises the function of the smoke barrier. During interview, facility staff confirmed that the magnetic release device was not operational. This condition could allow the spread of smoke between compartments, placing occupants at increased risk during a fire emergency”

“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 it was noted that the facility failed to provide emergency illumination that would operate automatically along the means of egress and failed to have the required illuminance with two lamps energized during emergencies in accordance with the 2012 Existing edition of the Life Safety Code of the NFPA 101 Sections 19.2.8, 7.8, 7.8.1.1, 7.8.1.2, 7.8.1.4 and 7.9.2.1. Findings include: 1. During the tour for life safety from fire, emergency lighting along means of egress were verified with the facility Institutional Programs Director (Employee #2) the following was determined: a. Observation of two (2) exit discharges on 04/21/2026 revealed that the pathway all the way from door to sidewalk did not have the required illuminance with two lamps energized during emergencies.”

“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 04/21/2026, it was determined that the facility failed to maintain exit and directional signs displayed in accordance with 7.10. Findings include: During observation of the administration area, it was noticed that no exit sing was present which stated obvious exit from Institutional Program office area and Administrative offices through stairs leading to exit discharge through lower floor to outside.”

“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 observations made during the Life Safety Code survey for life safety from fire of the facility with the facility’s Institutional Program Director (employee #2) on 04/21/2026, the facility failed to visually inspect and maintain fire suppression manual release and fire suppression system in accordance with the requirements NFPA 101, 2012 Edition, Section 18.3.2.5.1 through 18.3.2.5.4 and 9.2.3 and NFPA 96, 2011 Edition. Findings include: 1. Observation on April 21, 2026, at approximately 9:45 AM in the kitchen revealed that the ANSUL manual release inspection tag and releasing mechanism inspection tag lacked monthly inspection (date and initials) of the ANSUL system in accordance with the manufacturer’s maintenance manual was that requires it is completed at a minimum of 30-day intervals. 2. Observation on April 21, 2026, at approximately 9:45 AM in the kitchen revealed that the facility failed to ensure the commercial cooking fire suppression (Ansul) system is inspected at least every six (6) months in accordance with NFPA 96 and NFPA 17A this action does not ensure the system will function as intended in the event of a cooking fire. This deficient practice increases the risk of fire spread and could place patients, staff, and visitors at risk. 3. Observation on April 21, 2026, at approximately 9:45 AM in the kitchen revealed that the facility failed to maintain the kitchen exhaust hood system in operational condition in accordance with NFPA 96 this does not ensure proper removal of heat, grease-laden vapors, and smoke. This deficient practice increases the risk of fire and smoke accumulation and could result in fire spread, placing patients, staff, and visitors at risk.”

“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 04/21/2026 with the facility’s Institutional Program Director (Employee #2), it was determined that the facility failed to maintain initiation devices in all areas and in optimal condition. Findings include: 1. On 04/21/2026, approximately at 8:20 AM, smoke detector on main entrance was observed cover with dust. 2. On 04/21/2026, approximately at 9:25 AM, smoke detector on recreational Therapy was observed cover with dust.”

“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 Life Safety Code survey for life safety from fire of the facility with the facility’s Institutional Program Director (employee #2) on 04/21/2026 approximately at 8:45 AM, 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 main panel reported trouble signals that were not restored to normal within 200 seconds. No digital panel present in facility stating especific device. Observation on facility revealed smoke detectors on Recreational area and dining area hallway (clinical area) and administrative area were un operational. 2) Failure to properly label and maintain fire alarm system batteries in accordance with NFPA 72 does not ensure the reliability of the fire alarm system during a loss of primary power. This deficient practice could result in failure of the fire alarm system to function as intended, thereby placing patients, staff, and visitors at facility at risk. 3) Documentation on fire alarm was reviewed and no itemized inspection and testing of the smoke detectors, required information including the make/model, method of testing and manufacturer’s acceptable smoke.”

“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 observation, the facility failed to comply with NFPA 101 (2012 Edition), Section 19.3.5.12, which references NFPA 10 (2010 Edition), Section 6.1.3.8.1, that requires 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 Finding include: During the facility tour on 04/21/2026, it was observed that all fire extinguishers were inpected on April 2025, although facility had a log of monthly inspections, no monthly signature was found on extinguisher inspection card.”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 47384 Based on a recertification survey, observations made during the survey for life safety from fire , it was determined that the facility failed to have updated evacuation maps as required by the 2012 edition of the Life Safety Code of the NFPA Section 20.7.1.1 through 20.7.1.3, 20.7.1.8 through 20.7.2.3.3 Findings include: 1. During observation of the facility on 04/21/2026 it was noticed that evacuation maps located throughout the facility did not stated all possible exit routes available in the area it was located, it should state primary and alternate routs. Facility must re evaluate changes performed on facility and update evacuation. 2. During observation of the facility on 04/21/2026 it was noticed that at least two (2) evacuation maps were not legible due to mold like stains or water damage that covered most of the map.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 47384 Based on record review and interview made during the survey for life safety from fire on 04/21/2026, it was noticed that facility failed to hold Fire drills at expected and unexpected times under varying conditions. Findings include: During review of the Fire Drill documentation, it was observed that only one (1) drill had been performed for the first quarter of 2026 (February 2026). The code states that one exercise must be performed per shift per trimester.”

“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 04/21/2026, 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: No written records of inspection and testing are maintained and are available for review at the moment of the survey.”