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Based upon an Emergency Preparedness Program (EPP) survey performed on 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials' effort to maintain an integrated response during s disaster or emergency situation.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Safety Officer ( employee #7) on 08/28/2025 at 11:00 AM it was noted that the facility failed to include emerging infectious diseases as part of the emergency plan.

Based upon an Emergency Preparedness Program (EPP) survey performed on 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide means to shelter in place for patients, staff and volunteers who remain in the facility.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #7) on 08/28/2025 at 11:00 AM it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the Hospital during and after an emergency.

Based upon an Emergency Preparedness Program (EPP) survey performed on 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to ensure policies and procedures to facilitate the support of volunteers and other healthcare professionals in an emergency.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #7) on 08/28/2025 it was noted that the facility failed to stablished policies and procedures to ensure and facilitate the support of volunteers and other healthcare professionals in an emergency as required under §482.15(b)(6).

Based upon an Emergency Preparedness Program (EPP) survey performed on 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop arrangements with other facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to patients.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #7) on 08/28/2025 at 11:00 AM it was noted that the EP failed to have written arrangements with other dialysis facilities or other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to dialysis facilities.

Based upon an Emergency Preparedness Program (EPP) survey performed on 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to maintain documentation of all emergency preparedness training.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #7) on 08/28/2025 at 11:00 AM it was noted that the EP failed to provide documentation of training on emergency preparedness policies and procedures to all new and existing staff.

Based upon an Emergency Preparedness Program (EPP) survey performed on 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to conduct exercises to test the emergency plan every two years.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #7) on 08/28/2025 at 11:00 AM it was noted that the EP failed to conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise.

Based upon an Emergency Preparedness Program (EPP) survey performed on 08/28/2025 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to implement the emergency power system inspection, testing, and preventive maintenance requirements found in the Health Care Facilities Code NFPA 99, NFPA 110, and Life Safety Code.

Findings include:

During the review of the facilities Emergency Preparedness Program with the Safety Officer (employee #7) on 08/28/2025 at 11:00 AM it was noted that the EP failed to present evidence of all required inspections and testing.

Based on observations and interviews made during the survey for life safety from fire of the Hospital with the facility's Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to mantain the width of aisles or corridors serving as exit acces at least 4 feet and maintained to provide the convenient removal of nonambulatory patients 19.2.3.4, 19.2.3.5.

Findings include:

1. Approximately at 9:29 AM on 08/26/2025 unattended stretchers on both sides of the operating rooms hallway were observed reduceding exit access to two-foot six inches wide.

2. Approximately at 2:45 PM on 08/26/2025 an unattended linen cart, regular trash can and engineering department equipment car were observed on both sides of corrridor reduceding exit access to three-foot six inches wide.

The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.

The facility failed to provide exit doors in the means of egress readily accessible and free of all obstructions or impediments to full instant use in the case of fire or other emergencies in accordance with the requirements of NFPA 101, 2012 Edition, Section 19.2.2.2.5.1, 19.2.2.2.5.2 and 19.2.2.2.6.

Findings include:

Approximately at 9:58 AM on 08/26/2025 the emergency exit door prior to the Surgery Area was observed with the door frame misaligned. This misalignment can cause malfunctioning and the door to not open easily or get stuck.


The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to mantain doors with self-closing devices as required on 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8.


Findings include:

1.Approximately at 11:45 AM on 08/26/2025 it was observed that the smoke barrier door in hallway between Emergency Department and Radiology did not close flush.

2. Approximately at 12:10 PM on 08/26/2025 it was observed that the self-closing device on smoke barrier door on the second floor anex area was held opened, no automatic release operational.

The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to ensure exit and directional exit signs were provided and means of egress marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants in accordance with NFPA 101, 2012 Edition, Section 19.2.10.1 and 7.10.

Findings include:

1. Observation and interview on 08/26/2025 at approximately 9:30 AM on the Surgery Department it was noticed that no exit sign were provided in the operating rooms hallway area stating means of egress from the area.

2. Observation and interview on 08/26/2025 at approximately 10:30 AM, no exit sign stating obvious egress path was observed on corridor "Pasillo Sur" of Emergency Ward (cubicles 1 through 6).

3. Observation and interview on 08/26/2025 at approximately 10:30 AM, no exit sign was observed on either doors of Radiology department hallway.

4. Observation and interview on 08/27/2025 at approximately 9:30 AM, on the Medice third floor a exit sign was observed mounted backwards.

5. Observation and interview on 08/27/2025 at approximately 10:45 AM, on the pediatry deparment hallway, no exit sign was observed.

6. Observation and interview on 08/27/2025 at approximately 11:00 AM, an un energized exit sign (not lit) was observed in front of the elevator.

The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to maintain Hazardous areas protected by a fire barrier having 1-hour fire resistance rating in accordance with 8.7.1 or 19.3.5.9.

Findings include:

1. On 08/26/2025, approximately at 9:47 AM, in the machine area of the autoclaves in the operating room, it was observed that the gypsum board wall dividing the area showed perforations and did not cover completely around the autoclave. This deficiency would not provide the required protection for a hazard area according to code.


The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to mantain Alcohol Based Hand Rub Dispenser (ABHR) protected in accordance with 8.7.3.1.

Findings include:

1. Observation and interview on 08/26/2025 at approximately 11:15 AM, in the Triage area (Triage 1) on Emergency Ward, ABHR was observed on above a electric receptacle.

2. Observation and interview on 08/26/2025 at approximately 1:30 PM, on the third floor anex, ABHR was observed on above a electric receptacle between rooms #323 and #324.


The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to maintain initiation devices in all areas.

Findings include:

1. On 08/26/2025, approximately at 9:47 AM, in the medicine room of third floor, no smke detector was found.

2. On 08/26/2025, approximately at 10:47 AM, in the Physichal Therapy area, no smke detector was found.

3. On 08/26/2025, approximately at 2:47 PM, in the Intensive Care Unit, no smoke detectors were observed in 6 of the rooms.

4. On 08/27/2025, approximately at 10:00 AM, in the Respiratory Therapy Unit, no smoke detector was observed. .

The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), 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 08/26/2025 through 08/27/2025 revealed that there are no visual (strobe) or audible signals in public bathrooms (Surgery Recovery ).

The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation..

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to maintain the system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection.

Findings include:

1. Observation and interview on 08/26/2025 at approximately 11:30 AM, on the waiting area of Emergey Ward, it was observed that 6 out of 6 sprinkler heads were covered by excessive dust (Loaded Sprinklers).

2. Observation and interview on 08/26/2025 at approximately 1:30 PM, on Pediatric Ward, loose squetcheon was observed in front of cubicle #1.

3. Observation and interview on 08/26/2025 at approximately 1:30 PM, on Pediatric Ward, missing squetcheon were observed in the area.

4. Observation and interview on 08/27/2025 at approximately 2:30 PM, revealed that report named "Riser Inspection" stated that Water Motor Gong was inoperative.

The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), the facility failed to secure that Portable Fire Extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10.

Findings include:

1. On 08/26/2025 approximately at 9:00 AM A fire extinguisher was observed blocked by a stretcher in the hallway of the operating rooms.

2. On 08/26/2025 approximately at 10:30 AM a fire extinguisher was observed blocked by a dirty linnen cart in front of the environmental care and management room.

3. On 08/26/2025 approximately at 10:30 AM a fire extinguisher was observed obstructed by a counter top and papers between Blood Bank and Hematology area in the Laboratory Department.

4. On 08/27/2025 approximately at 9:30 AM a fire extinguisher was observed obstructed by a regular trash can in the Intensive Care Unit.


The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), 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 08/26/2024 through 08/27/2024 from 8:00 AM through 4:00 PM, patient's sleeping room doors were tested it was found that patient's sleeping rooms do not latch when the doors are closed, this can permit smoke, fire and noxious gases to enter the rooms in the event of a fire. All doors at the hospital must be verified at least monthly and appropriate documentation must be available upon request.

Second floor: #201, #202, #203, #204, #206, #207, #208, #209, #210, #211, #214, #215, #216

Third floor: #306, #312, #314, #316, #319, #320, #322, #323, #324, #325, #326, #327, #328, #329, #330,
#331, #332

Fourth floor: #402, #403, #404, #406, #407, #407, #409, #410

The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.

Based on observations and document review made during the survey for life safety from fire on 08/19/2025 through 08/21/2025 from 8:00 AM to 4:00 PM, it was determined that the facility failed to ensure all master, area, and local alarm systems used for medical gas and vacuum systems comply with appropriate Category warning system requirements, as applicable. 5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99)

Findings include:

1. A pattern of non labeling the Medical Gas outputs was observed throughout the facility.

2. A pattern of non labeling the Medical Gas Shutoff valves was observed throughout the facility.

The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to ensure Essential Electrical System (EES) is maintained by conducting three-year four-hour load bank test in accordance with the requirements of NFPA 99, 2012 Edition Section 6 and NFPA 110, 2012 Edition Section 8.4.9.

Findings include:

Document review and interview on 08/26/2025 at approximately 3:05 PM the documents reviewed did not evidencea a 36 month test for the EES.


The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.

Based on observations made during the survey for life safety from fire with the facility's Safety Officer (Employee #7) and the Engineering Department Manager (employee #8), it was determined that the facility failed to observe precautionary measures to ensure safety on the cylinder storage as requested on 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)


Findings include:

Unprotected cylinders were observed in the Medical Gas Cage:

1. Twenty eight (28) Type E Oxygen tanks were observed un chained, unsecured.

2. Forty (40) Type H Nitrous Oxide tanks were observed un chained, unsecured.

3. Five (5) Type H Nitrogen tanks were observed un chained, unsecured.

4. Seventeen (17) Type H Oxigen tanks were observed un chained, unsecured

5.Three (3) Type H Helium tanks were observed un chained, unsecured

The finding was verified by the Safety Officer and Engineering Department Manager at the time of the observation.