Cozad Community Hospital

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 46123 Based on review of facility policies, Emergency Department (ED) tour and staff interviews, the facility failed to ensure that outdated supplies were removed from the ED patient care areas. This failed practice has the potential to affect all patients treated in the ED. On average the facility treats 140 ED patients per month. Findings are: A. The Surveyor requested a policy and procedure related to the process and responsibility of checking supply outdates throughout the facility. The Facility failed to provide a policy and procedure prior to surveyor exit. B. Outdated supplies in ED triage rooms included the following: - Rhino Rockets (a device used to stop severe nose bleeds.) Small x6 Expired 8/7/22 Small x5 Expired 4/21/25 Small x8 Expired 1/1/23 Medium x5 Expired 2/26/22 Medium x8 Expired 1/31/24 Medium x1 Expired 4/27/25 -Disposable Ear Speculum (a cone shaped tip that attaches to the device that is used to look in the ear.) 3millimeter (mm) x1 Expired 6/23 4mm x1 Expired 6/24/26 6mm x1 Expired 2/23 6mm x3 Expired 5/19 - HER -SPEC Vaginal Speculum (a one time use device used to complete a vaginal exam.) Small x1 Expired 12/13/21 Small x1 Expired 5/15/24 Medium x1 Expired 12/12/21 Medium x1 Expired 3/9/23 Medium x1 Expired 5/15/24 Medium x1 Expired 4/15/26 Large x1 Expired 3/9/23 Large x1 Expired 5/15/24 - The Morgan Medi-flow lens (a device that is used to continuously flush an injured eye with fluid.) x1 Expired 7/21, x1 Expired 10/24 - Nitra Test Paper (a special paper used to test body fluid for acidic or base, it changes color depending on fluid.) x1 Expired 6/20/2013 - Lubricating Jelly x1 Expired 9/30/24, x1 Expired 2/28/25 - Chloraprep Single Swab Stick x2 Expired 7/18, x5 Expired 7/25 - Alcohol Swab Sticks x6 Expired 11/23 - Povidone-Iodine Swab Stick x2 Expired 3/25 - Sterile 0.9% Sodium Chloride Inhalation Solution x5 Expired 10/21 - IV Extension Set x1 Expired 12/31/23 C. Interview with Director of Nursing (7/23/26 at 9:00 AM) revealed, the Nursing Department checks for outdates monthly in their departments. The monthly department checks are not documented anywhere when completed. -Interview with the Compliance Officer (7/23/26 at 11:00 AM) confirmed outdates of the above supplies that were removed from the EDs two triage rooms. The Compliance Officer also confirmed that the facility lacks a policy for checking and removal of outdated supplies.”

“42 CFR 485.623 The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, Existing Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Cozad Community Hospital is a one-story building that was built in 1977 with an addition added in 2000. The original building is a Type II (111) construction, and the addition is also Type II (111) construction for which the entire facility is fully sprinkled with a wet system. There is supervised smoke detection located in the corridors and spaces open to the corridors along with heat detection in the hazardous areas. The facility has 20 certified beds. At the time of the survey the census was 6. Cozad Community Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 04548 Based on observation and interview, the facility failed to ensure hazardous areas provided separation from all other spaces This deficient practice would allow smoke and fire to migrate into the exiting corridor. This has the potential to affect approximately 10 occupants in one of five smoke zones. Findings are: Observations on 07/23/26 at 12:30 P.M. revealed the door to the Storage Pantry open to the kitchen was wedged open and would not close during an emergency. During an interview on 07/23/26 at 12:30 P.M., Maintenance staff, confirmed that the door was wedged open.”

“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: 04548 Based on observation and interview, the facility failed to ensure that doors to the corridors are provided with a means suitable for keeping the door closed. This deficient practice would not prevent the spread of fire and smoke affecting approximately 10 occupants. Findings are: Observations on 07/23/26 at 12:15 P.M. revealed the door to the Dirty Laundry Room in the service corridor did not close properly and would not latch within the doorframe. During an interview on 07/23/26 at 12:15 P.M., Maintenance staff, confirmed that the door was not closing and not latching properly.”

“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: 04548 Based on documentation review and interview, the facility failed to conduct fire drills under varying conditions for three of four quarters reviewed. This condition would not provide training for staff on their duties, life safety procedures and the fire protection devices in their assigned areas. The deficient practice would affect fire procedure response for all occupants. Findings are: On 07/23/26 at 1:00 P.M., the facility’s fire drill documentation showed only one fire drill the past four quarters for the night shift and two fire drills in the past four quarters for the day shift . During interview on 07/23/26 at 1:00 P.M., Maintenance Director advised that the facility was aware of the fire drill requirement of one per quarter per shift.”

“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: 04548 Based on interview and documentation review, the facility failed to implement an annual testing and inspection program to document the integrity and operation of all fire rated doors throughout the facility. This deficient practice failed to ensure that the fire doors would operate as designed to prevent the spread of fire and smoke and affected all occupants in all smoke compartments. Findings are: Documentation review on 07/23/26 at 1:10 P.M. revealed that the facility failed to provide written documentation of annual inspections and testing of all fire rated doors throughout the facility. During an interview on 07/23/26 at 1:10 P.M., Maintenance Staff A confirmed the lack of complete annual fire rated door inspection documentation.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 04548 Based on record review and interview, the facility failed to conduct receptacle testing for non-hospital grade electrical outlets at resident care locations. This deficient practice would create electrical injury and fire hazards which would affect all occupants. Findings are: Record review on 07-23-26 at 1:20 P.M. revealed, facility failed to provide testing documentation for each receptacle at patient care areas and failed to provide the tests that were conducted. During an interview on 07-23-26 at 1:20 P.M., Maintenance confirmed the lack of testing to non-hospital grade receptacles in patient rooms. NFPA Standard: NFPA 99, 2012, 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 2012 NFPA 99 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 04548 Based on observation and interview, the facility failed to post proper signage on doors in areas where individual oxygen cylinders and liquid oxygen containers are stored. This deficient practice could result in an oxygen enriched atmosphere creating an increased fire hazard affecting approximately 10 occupants. Findings are: Observations on 07/23/26 at 11:45 A.M. revealed the Equipment Room on the Patient wing was storing Oxygen cylinders without proper signage. During an interview on 07/23/26 at 11:45 A.M., Maintenance staff confirmed the missing signage. NFPA 99 sec11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room. CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING”