Encompass Health Rehabilitation Hospital of San Ju

“LICENSURE OF PERSONNEL CFR(s): 482.11(c) The hospital must assure that personnel are licensed or meet other applicable standards that are required by State or local laws. This Standard is not met as evidenced by: 51782 Based on the review of ten 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 Influenza Vaccine or refuse, Criminal record certificated and Health certificate for 4 out of 4 Medical Staff (MS). (M.S.C.F. #6, #8, #9 and #10). Findings include: 1.During the credential files review of Medical Staff (M.S.C.F.) conducted from 07/14/2026 from 10:30 AM to 3:30 PM, with the Quality Director (employee #1), the following were found: a. One out of ten credential file did not have updated evidence of Health certificated accordance to Law #232-2000 Puerto Rico Health Certification Law, expired on March 7, 2026 (M.S.C.F #6). b. One out of ten credential files did not have updated evidence of criminal record certificated in accordance with Law #254 of July 27, 1974, Puerto Rico Criminal Record Certification, expired on 02/20/2026 (M.S.C.F #8). c. Three out of ten credential file did not have evidence of Influenza vaccines or refuse certification, accordance to state administrative order #244 of 10/10/2008 of the Department of health and the state administrative order #362 of 12/8/16 of the Department of health (M.S.C.F #8, #9 and #10).”

“PHARMACIST SUPERVISION OF SERVICES CFR(s): 482.25(b)(1) §482.25(b)(1) - All compounding, packaging, and dispensing of drugs and biologicals must be under the supervision of a pharmacist and performed consistent with State and Federal laws. This Standard is not met as evidenced by: 47632 Based on observation and staff interview, it was determined that the facility failed to maintain the controlled subtances storage area in a safe and organized manner to ensure the proper storage and security of controlled medications. Findings include: On 07/15/2026 at 1:22 PM, during a tour of the Pharmacy Department, it was observed in the controlled substances storage room that multiple cardboard boxes were stored on the side and top of the Pyxis automated medication dispensing system used to store controlled medications. The quality and placement of the boxes obstructed the space surrounding the equipment. During the same observation, noted that the controlled subtances storage room was not equipped with a fire alarm device. The Director of Pharmacy (employee #10) was present during the observation and acknowledged the conditions observed.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 47384 Based on observation performed on 07/14/2026 through 07/15/2026, it was determined that the Facility failed to maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured. Findings include: 1. Ceiling tiles with water stain on the physical therapy room benieth the car simulator. 2. Ceiling tiles with water damage on room #302 3. One (1) of two (2) broken window shades on room #302 4. Ceiling tiles with water damage on room #304. 5. Air condition (AC) vent observed with rust on room #304. 6. One missing drawer in nightstand of bed #304 B. 7. Ceiling tiles with water damage on room #306. 8. Ceiling tiles with water damage on room #309. 9. Grab bar observerd loose on the toilet area of room #309. 10. Ceiling tiles with water damage on room #312. 11. Ceiling tiles with water damage on the hallway in front of room #314. 12. Ceiling tiles with water damage next to the air conditioning vent on room #314 A and #314 B 13. Peeling paint in wall of room #314 B. 14. Grab bar observerd loose on the toilet area of room #315. 15. Ceiling tiles with water damage next to the air conditioning vent on room #315 16. Ceiling tiles with water damage on room #310 B. 17. Grab bar observerd loose on the toilet area of room #316.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 07/14/2026 through 07/15/2026 from 8:00 AM to 3:30 PM with the facility’s Safety Officer (employee #7), it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101. Findings include: The Life Safety from Fire survey was performed on 07/14/2026 through 07/15/2026, for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the CMS2567 form ( K211, K293, K343, K345, K353, K363, K371, K372, K761, K781, K912, K926).”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47632 Based on observation, staff interview and review of the Infection Prevention and control policies and procedures, it was determined that the facility failed to ensure adherence to hand hygiene practices in accordance with accepted infection prevention and control program and nationally recognized infection prevention guidelines. Findings include: On 07/16/2026 at 8:54 AM, during a tour of the patient care units, it was observed a Registered Nurse (employee #13) providing patient care in room 304-B. After removing and discarding the soiled gloves, the Registered Nurse had two opportunities to perform hand hygiene by using an alcohol based hand sanitizer or washing her hands with soap and water before donning a clear pair of gloves. The Registered Nurse donned a clean pair of gloves without performing hand hygiene.”

“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: 47632 Based on observation and staff interview, it was determined that the facility failed to maintain the controlled substances storage room in aclean and sanitary condition to support the Infection Prevention and Control Program. Findings include: On 07/15/2026 at 1:22 PM, during a tour of the Pharmacy Department , it was observed in the controlled substances storage room that multiples cardboard boxes were stored on the side and top of the Pyxis automated medication dispensing system, where controlled medications were stored. During the same observation, an acoustical ceiling tile located above the Pyxis machine was stained and showed evidence of moisture damage. The Director of Pharmacy was present during the observation and acknowledged the conditions observed.”

“ANTIBIOTIC STEWARDSHIP COORDINATION CFR(s): §482.42(b)(2) The hospital-wide antibiotic stewardship program: (i) Demonstrates coordination among all components of the hospital responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services; This Standard is not met as evidenced by: 47632 Based on staff interview, review of the Policy “Antimicrobial Stewardship Subcommitte Regulation”, and review of the Antibiotic Stewardship Committe meeting minutes, it was determined that the facility failed to implement the Antibiotic Stewardship Program in accordance with it is approved policy by failing to conduct the Antimicrobial Stewardship Subcommitte meetings at the required frecuency. Findings include: On 07/14/2026 at 1:33 PM, during an interview with the Director of Pharmacy (employee #10) and review of the policy “Antimicrobial Stewardship Subcommitte Regulation,” approved June 2021 with a next review date of January 2027, Section 7:”Subcommitte Meetings,” subsection 7.1 stated: “The Subcommitte meeting shall be held every three months, for a total of four meetings per year.” A review of the Antimicrobial Stewardship Committe meeting minutes revealed that during calendar year 2025, the subcommitte conducted three meetings, held on January 28, 2025; June 19, 2025; and November 24, 2025. Further review of the meeting minutes revealed that the subcommitte had conducted one meeting during calendar year 2026, held on May 19, 2026. During an interview, the Health System Director (employee #9) stated Infectious Disease Physician serving on the Antimicrobial Stewardship Committe had resigned. The Health System Director further stated that following the resignation, the facility lacked an infectious disease specialist assigned to the committee for a period in 2024, resulting in the cancellation of scheduled committee meetings.”

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 07/15/2026, 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, it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the unit during and after an emergency.”

“Based on tests to equipment, interviews and observations made during the survey for Life Safety from Fire on 07/14/2026 through 07/15/2026, it was determined that the facility does not meet some applicable provision of the 2012 edition of Life Safety Code of the NFPA 101. Type of Structure: Facility occupies a wing on the third floor of UDH Hopsital, Type I (443), protected non-combustible construction with one (2) smoke compartments and automatic (wet) sprinkler system. The findings that follow demonstrate noncompliance with Title 42, Code of Federal Regulations, 482.41 (b) et seq. (Life Safety from Fire). The facility has 35 certified beds. At the time of the survey the census was 34 inpatient and 41 outpatient.”

“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, it was determine that the facility failed to maintain exit discharge doors in a safe, readily operable condition in accordance with NFPA 101 (2012), Sections 7.2.1 and 19.2.1. This deficient practice could delay or impede the evacuation of occupants during an emergency, affecting the safety of patients, staff, and visitors. Findings include: Findings observed on both doors of emergency exit #5: 1. On 07/14/2026 at approximately 10:40 AM, observation of the first exit discharge door located on the south hallway revealed the panic (push) bar was missing parts. Interview with the Safety Officer at the time of the observation confirmed the condition and acknowledged that adjustment or repair of the panic hardware was needed. 2. On 07/14/2026 at approximately 10:40 AM, observation of the second exit discharge door located on the south hallway revealed the door required excessive force to operate, making the door difficult to open from the egress side. The condition could delay occupant evacuation during an emergency. Also the fire door rating label had been painted over, preventing verification of the door’s fire-resistance rating. In addition, the door frame exhibited rust and corrosion, indicating deterioration of the door assembly. Interview with the Safety Officer at 10:45 AM confirmed the condition and acknowledged that corrective action was required to restore the door assembly to compliance with Life Safety Code requirements.”

“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 07/14/2026 through 07/15/2026, it was determined that the facility failed to maintain exit and directional signs displayed in accordance with 7.10. Findings includes: 1. At approximately 8:50 AM it was found that the exit sign located in the hallway between both exits from the outpatient therapy area located in the outpatient clinic located at Hospital C (Cardiovascular Hospital) was no oprational. 2. At approximately 9:05 AM it was found that an exit sign is needed to be installed in the therapy area in order to state obvious alternate exit route through documetation area and main entrance of the outpatient clinic in the Hospital C (Cardiovascular Hospital). 3. At approximately 10:00 AM it was found that two (2) exit signs are needed to be installed in the physical therapy area (gym) no exit sings were noted stating obvious exit rout from area. The finding was verified by the Safety Officer at the time of the observation.”

“Fire Alarm System - Notification CFR(s): NFPA 101 Fire Alarm - Notification 2012 EXISTING Positive alarm sequence in accordance with 9.6.3.4 are permitted in buildings protected throughout by a sprinkler system. Occupant notification is provided automatically in accordance with 9.6.3 by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of a fire. 19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1) This Standard is not met as evidenced by: 47384 Based on observation and interview, it was determined that the facility failed to ensure that occupant notification is provided automatically in accordance with NFPA 101, 2012 Edition, Section 9.6.3 by audible and visual signals. Findings include: Observation and interview on 07/14/2025 at approximately 8:20 AM revealed that there are no visual (strobe) or audible signal in public area bathrooms (Out patient waiting area). The finding was verified by the Safety Officer at the time of the observation.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 47384 Based on observation and interview, the facility failed to ensure the fire alarm system impairment was properly managed in accordance with NFPA 72, 2010 Edition, Section 10.19, and NFPA 101, 2012 Edition, Section 9.6.1.6, by failing to properly respond to a fire alarm system trouble condition. Findings include: During observation on 07/14/2026 at approximately 9:23 AM, the fire alarm main panel on it was observed displaying a trouble signal with the acknowledgement function disabled. The system indicated a trouble condition: 1. “Habitacion 319 Missing” recorded at approximately 4:26:48 P.M. on Wednesday, July 8, 2026 Review of system status revealed the condition was not restored to normal within 200 seconds as required for prompt response and correction of fire alarm impairments. 2. During observation, it was noticed that the controlled subtances storage room was not equipped with a fire alarm device. The finding was verified by the Safety Officer at the time of the observation.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 47384 Based on observation and interview, the facility failed to maintain and ensure proper installation and monitoring of the automatic sprinkler system in accordance with NFPA 25, 2011 Edition, and NFPA 101, 2012 Edition, Section 9.7.5. Findings include: 1. During the survey performed on 07/14/2026 at approximately at 10:10 AM in the Physical Therapy Area (gym) it was noticed that eleven (11) out of eighteen (18) sprinkler heads were found loaded (full of dust). 2. During the survey performed on 07/15/2026 at approximately at 8:30 AM at Room #317 bed A and Bed B, sprinkler heads were observed with a loaded condition present. 3. During the survey performed on 07/15/2026 it was identified that the room divider curtains were tangled or covering the sprinklerheds in rooms #303, #309, #312, #313. Failure to maintain required inspection, testing, and maintenance records and ensure proper condition of sprinkler system components could result in delayed or ineffective sprinkler system response during a fire event.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire, it was determined that the facility failed to protect corridors at clinical floors ( doors do not latch) as required by the 2012 edition of the Life Safety Code of the NFPA Section 19.3.6.3. Findings include: During the tour for life safety from fire on 07/21/2026 through 07/22/2026 from 8:00 AM through 3:30 PM, patient’s sleeping room doors were tested it was found that patient’s sleeping rooms #210, #211, #212, #217, #221 do not latch when the doors are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request. The finding was verified by the Engineering Director at the time of the observation.”

“Subdivision of Building Spaces - Smoke Compar CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Compartments 2012 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping floor with a 30 or more patient bed capacity. Size of compartments cannot exceed 22,500 square feet or a 200-foot travel distance from any point in the compartment to a door in the smoke barrier. 19.3.7.1, 19.3.7.2 Detail in REMARKS zone dimensions including length of zones and dead-end corridors. This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire with the facility’s Safety Officer (employee #7), it was determined that the facility failed to ensure that corridors are separated from use areas by walls constructed to provide at least 30 minutes of fire resistance at the electric room located near treatment area as required by the 2012 edition of the Life Safety Code of the NFPA Section 19.3.6.1, 19.3.6.2.1 and 19.3.6.5. Findings include: During the observational tour for life safety from fire, all rooms located at corridors were visited with the Safety Officer (employee #7) on 07/14/2026 at 8:10 AM. During observation of the Fire Alarm main panel located on the electric room it was noticed that this room has circuit breaker panels and electrical tubing. The electrical tubing that supplies electricity to the patient care area was found passing through the wall above the door of this room over the drop ceiling. It was observed that the wall was not sealed (penetrations) to prevent the passage of smoke into the general hallway area to patients room and directly to the Information Managment Area. This penetrations will also allow smoke into the corridor through the drop ceiling.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 47384 Based on observation and interview, the facility failed to maintain smoke barrier doors in accordance with NFPA 101 (2012) Sections 18/19.3.7.8. The deficient practice could permit the passage of smoke between smoke compartments during a fire emergency, reducing the effectiveness of the smoke barrier and potentially affecting the safety of patients, staff, and visitors. Findings include: 1. On 07/14/2026 at approximately 10:30 AM, observation of the north side smoke barrier door revealed the paired doors did not close flush, leaving a visible gap between the doors when in the closed position. Additionally, penetrations were observed beneath the smoke barrier within the plenum space, compromising the integrity of the smoke barrier assembly. 2. On 07/14/2026 at approximately 10:30 AM, observation of the south side smoke barrier door revealed the door required approximately 14 seconds to fully close after release. The delayed closing could affect the timely formation of the smoke barrier during a fire emergency. The finding was verified by the Safety Officer at the time of the observation.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 07/14/2025 through 07/15/2026 from 8:00 AM to 3:30 PM with the facility’s Safety Officer (Employee #7), it was determined that the facility failed to ensure fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (2010 NFPA 80). Findings include: 1. No written records of inspection and testing are maintained and are available for review at the moment of the survey. 2. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, were not routinely inspected as part of the facility maintenance program.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 07/14/2026 from 8:00 AM to 3:30 PM with the facility’s Safety Officer (Employee #7), it was determined that the facility failed to maintain areas free of portable space heating devices. 18.7.8, 19.7.8 Findings include: One (1) Portable heater was obseverd on the Speach Therapy office.”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observations made during the survey for life safety from fire on 07/15/2026, it was determined that the facility failed to maintain electrical safety as required in 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) Findings include: 1) During observation of the outpatient clinic at approximately 8:45 AM, in the physical treatment area it was noticed that the recepatacle next to the Chattanoga Cold Pack and Hydraterm machine was not a ground-fault circuit interrupters (GFCI). 2) During review of receptacles inspection report it was noted that four (4) floor receptacles were in need of replacement in the outpatient clinic, physical treatment area. 3) During observation of the Dysphagia treatment Room, ice and water machine recepatacle were not a ground-fault circuit interrupters (GFCI). 4) During observation of the physical treatment in patient area it was noticed that the recepatacle next to the Chattanoga Cold Pack machine was not a ground-fault circuit interrupters (GFCI). 5) During observation of the physical treatment in patient area it was noticed that the recepatacle next to the water dispensing machine was not a ground-fault circuit interrupters (GFCI). The findings were verified by the Safety Officer at the time of the observation.”

“Gas Equipment - Qualifications and Training CFR(s): NFPA 101 Gas Equipment - Qualifications and Training of Personnel Personnel concerned with the application, maintenance and handling of medical gases and cylinders are trained on the risk. Facilities provide continuing education, including safety guidelines and usage requirements. Equipment is serviced only by personnel trained in the maintenance and operation of equipment. 11.5.2.1 (NFPA 99) This Standard is not met as evidenced by: 47384 Based on observation and interview, it was determine the facility failed to ensure that personnel responsible for the application, maintenance and handling of medical gases are trained on the risks, and safety requirements including medical gas shut off are trained in the event of an emergency in accordance with the requirements of NFPA 99, 2012 Edition, Section 11.5.2.1. Findings include: Observation and interview on 07/15/2026 at approximately 10:05 AM two nursing staff personel were requested to shut oxygen to Room 310, and did not know proper action to perform. Safety Officer agreed that the personel was not sure of where the shut off oxygen was located, or shut off procedure and direction would be posted and staff trained on medical gas safety requirements in the event of an emergency.”