Northeastern Health System

“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: 46363 Based on record review and staff interview, the facility failed to maintain and test the required semi-annual kitchen hood inspections. This deficient practice has the potential to affect 51 of 51 patients in the facility, as identified by the administrator on 02/05/26. Findings: On 02/05/26 from 1:00 p.m. to 2:20 p.m. a review of the facility’s maintenance records was conducted and the facility could not provide the last 2 semi-annual kitchen hood inspections from January 2025 through February 2026. On 02/05/26 from 1:00 p.m. to 2:20 p.m. a review of the facility’s maintenance records was conducted and the maintenance director was interviewed. The maintenance director acknowledged that the last 2 semi-annual kitchen hood inspections from January 2025 through February 2026 were not performed.”

“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: 46363 Based on record review and staff interview, the facility failed to maintain and test a complete automatic sprinkler system. This deficient practice has the potential to affect 51 of 51 patients in the facility, as identified by the administrator on 02/05/26. Findings: On 02/05/26 from 1:00 p.m. to 2:20 p.m. a review of the facility’s maintenance records was conducted and the facility could not supply quarterly sprinkler inspection reports for quarters 2 and 3 of year 2025. On 02/05/26 from 1:00 p.m. to 2:20 p.m. a review of the facility’s maintenance records was conducted and the maintenance director was interviewed. The maintenance director acknowledged that the quarterly sprinkler inspections were not performed in quarters 2 and 3 of 2025.”

“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: 46363 Based on record review and interview, the facility failed to conduct the required number of fire drills from January 2025 through February 2026. This had the potential to affect 51 of 51 patients in the facility, as identified by the administrator on 02/05/26. Findings: On 02/05/26 from 1:00 p.m. to 2:20 p.m. a review of the facility’s maintenance records was conducted and there was no documentation the facility conducted fire drills for the following shifts: a. The second shift for the first quarter of 2025 or 2026. b. The second shift for the third quarter of 2025. c. The first shift for the fourth quarter of 2025. On 02/05/26 from 1:00 p.m. to 2:20 p.m. a review of the facility’s maintenance records were conducted and the maintenance director was interviewed. The maintenance director acknowledged the missing 3 fire drills.”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 6 (NFPA 99) This Standard is not met as evidenced by: 46363 Based on observation and staff interview, the facility failed to provide appropriate equipment for the emergency generator as required by NFPA 99 Remote Emergency Stop (Table 6.4.1.1.16.2 safety indications and shutdowns). This deficient practice has the potential to affect 51 of 51 patients in the facility, as identified by the administrator on 02/05/26. Findings: On 02/05/26 from 2:20 p.m. to 3:45 p.m. a review of the facility’s maintenance records was conducted and the facility could not provide the last 2 semi-annual kitchen hood inspections from January 2025 through February 2026. On 02/05/26 from 1:00 p.m. to 2:20 p.m. a review of the facility’s maintenance records was conducted and the maintenance director was interviewed. The maintenance director acknowledged that the last 2 semi-annual kitchen hood inspections from January 2025 through February 2026 were not performed. Based on observation and staff interview, the facility failed to provide appropriate equipment for the emergency generator as required by NFPA 99 Remote Emergency Stop (Table 6.4.1.1.16.2 safety indications and shutdowns). This deficient practice could affect 39 of 39 residents who currently reside in the facility, as identified by the administrator on 05/29/25. The facility had a census of 39 residents. Findings: 1. A tour of the facility was conducted on 05/29/25 from 11:20 a.m. to 2:00 p.m. and the facilities generator did not have a remote emergency stop button (kill switch). 2. On 05/29/25 at 12:15 p.m. the maintenance supervisor acknowledged that the generator did not have a remote stop button (kill switch).”

“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: 46363 Based on observation and staff interview on 02/05/26, the facility failed to properly secure and store all the oxygen cylinder bottles. Findings: On 02/05/26 from 2:20 p.m. to 4:00 p.m. a tour of the facility was conducted and located on the 2nd floor in the surgery storage closet, 15 oxygen cylinder bottles were observed sitting on the floor without being properly secured. On 02/05/26 from 1:00 p.m. to 2:20 p.m. a tour of the facility was conducted and the maintenance director was interviewed. The maintenance director acknowledged 15 oxygen cylinder bottles were sitting on the floor without being properly secured.”

“ORGANIZATION CFR(s): 482.28(a) Organization This Standard is not met as evidenced by: 41506 Based on observation, record review, and interview, the facility failed to ensure dietary staff maintained safe food storage practices for 20 of 20 cardboard boxes in the refrigerator. Findings: On 06/04/25 at 2:00 p.m. observations in the dietary department’s refrigerators showed nutritional food items being stored in their original cardboard boxes. The cardboard boxes were observed to be stacked on top of one another in the refrigerator where the bottom boxes were beginning to collapse from the weight of the top box in the refrigerator. Many of the cardboard boxes were also noted to be softened from the moisture in the refrigerator. The CDC guidelines on Food Safety in Healthcare, read in part, “The USDA and the CDC advise against storing cardboard boxes in refrigerators. While cardboard boxes can be a convenient storage solution, it’s not recommended for food safety due to the potential for moisture, bacteria, and increasing the risk of contamination. Moisture can damage the cardboard, potentially affecting the contents or creating a breeding ground for bacteria. Cardboard may not be as effective at maintaining consistent temperatures of food items, causing temperature fluctuations which can potentially affect the stored items.” On 06/04/25 at 2:40 p.m. Staff T stated: 1. The dietary personnel had recently received a food supply shipment and the refrigerated food items were still being stored in their original boxes in the refrigerator. 2. They were aware of some of the food safety guidelines pertaining to cardboard box use in refrigerators. 3. They stated the facility followed CDC and the Oklahoma Dietary Manual.”

“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: 41506 Based on observation, record review, and interview, the facility failed to ensure staff maintained a functional and sanitary environment by: 1. failing to ensure 10 of 10 reprocessed endoscopes were stored in an endoscope cabinet and 2. failing to ensure 5 of 5 sharp containers were secured in place. Findings: 1. failing to ensure 10 of 10 reprocessed endoscopes were stored in an endoscope cabinet that circulated HEPA filtered air and failing to ensure the endoscopes had an additional 10-minute air purge, after reprocessing the endoscopes in an AER and prior to storing, An observation on 6/02/25 at 3:40 p.m. in the endoscope department showed 10 reprocessed endoscopes hanging in a cabinet that was not equipped with a HEPA filter. A review of ANSI/AAMI ST91:2021, March 2022: “Flexible and semi-rigid endoscope processing in health care facilities,” read in part, “Research has shown there have been multi-drug-resistant organism infection outbreaks related to flexible endoscopes. Review of the processes and procedures used to reprocess these complex and sophisticated devices revealed failures in reprocessing steps that could jeopardize patient safety. Thorough drying has been shown to reduce the risk of microbial contamination following HLD from the recontamination of the endoscope by waterborne microorganisms during rinsing...” “Drying cabinets include a drying system that circulates HEPA- filtered air through the cabinet while filtered air under pressure is forced through the endoscope channels or store endoscopes in a closed cabinet with HEPA- filtered air that provides positive pressure and allows air circulation around the flexible endoscopes.” A review of the facility policy titled “Care and Cleaning of Endoscopes”, dated 01/05/24, read in part, “All endoscopes will be terminally disinfected after each use and the channels flushed with 70% alcohol. At the end of each day all of the ports will be left open to air in order to promote drying.” On 06/02/25 at 3:40 p.m. Staff P stated they were not aware of or familiar with the updated AAMI ST91:2021 that was approved in March 2022 when they reviewed their policy. They stated they mainly depended upon the air purge dry time built into the AER and performed a manual air purge, as needed. Staff P stated they did not perform a 10-minute additional air purge after HLD and stated the endoscope storage cabinet did not have a HEPA- filtered air system in place. 2. failing to ensure 5 of 5 sharp containers were secured in place to ensure stability and failing to ensure there was a closing mechanism on the sharp containers to minimize hand-sharp injuries and exposure to contents. Observations on 06/02/25 at 3:30 p.m. showed 5 sharp containers located on the storage carts in the postoperative area that were not secured in place and had accessible openings with no closing mechanism in place. A review of OSHA 29CFR 1910.1030(d)(2)(i), read in part, “Sharps containers must be puncture-resistant with leakproof sides and bottoms and labeled to warn of hazardous contents. Containers must be closable with a lid, flap, or door. Containers must be secured and kept upright to prevent spillage.” A review of AORN Guidelines for Perioperative Practice, 2021 Edition: Guideline for Sharps Safety, read in part, “Select sharp containers using functionality, accessibility, accommodation, and visibility criteria; Leak resistance, a mechanism for closing that minimizes exposure to contents and hand injuries, resistant to being opened manually, stability and not prone to tipping. Keep sharps disposal receptacles secured in an upright position when in use.” On 06/02/25 at 3:30 p.m. Staff O stated they were not aware that sharps containers should be secured in place or that they required a closing mechanism (lid). On 06/04/25 at 2:30 p.m. Staff N stated the facility followed the infection control guidelines from CDC, APIC, AAMI, and AORN and they were not aware of the above infection control issues.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 41506 Based on observation, record review, and interview, the facility failed to ensure: 1. surgical staff processed surgical items according to acceptable sterilization guidelines for 20 of 20 paper-plastic peel pouches that were not light weight and/or low profile, and 2. surgical staff adhered to acceptable standards for wearing surgical mask for 3 of 3 (Staff I, J, and W) and wearing cover jackets for 4 of 4 (Staff H, K, X, and Y) surgical staff. Findings: 1. failing to ensure surgical staff processed surgical items according to acceptable sterilization guidelines and/or manufacturer’s IFU when processing and sterilizing surgical items in paper-plastic peel pouches by observations of 20 of 20 paper-plastic peel pouches that were not light weight and/or low profile, Observations on 06/02/25 at 2:40 p.m. in the Sterile Supply Room showed 20 sterile items processed in paper-plastic peel pouches that were not low profile with visible tenting and creasing of the sterile packages. Further observations showed the sterile items processed in paper-plastic peel pouches were not light weight with visible stress on the package’s sealed seams. A review of the AORN Perioperative Nursing: Scope and Standards of Practice 2021, read in part, “Perioperative RNs are to follow the AORN Guidelines for Perioperative Practice to guide their scope of professional responsibility...” A review of the AORN Guidelines for Perioperative Practice 2021 edition: Guidelines for Packaging Systems, read in part, “Use peel pouches (i.e., paper-plastic, polyethylene material, polyester film) according to a manufacturer IFU and/or according to AORN packaging guidelines. Sterile items processed in peel pouches should be light weight and low profile to maintain the sterility of the package contents and not compromise the package or the seal integrity (caused by heavy items or tenting). Sterility is event-related and not time-related. The sterility of an item does not change with the passage of time, but may be affected by events such as, amount of handling, improper packaging and storage, and properties of the packing material.” On 06/02/25 at 3:20 p.m. Staff L stated: 1. They thought that the sterile items processed in the paper-plastic peel pouches were acceptable. 2. The facility did not have a policy specific on paper-plastic peel pouch guideline requirements or a policy stating the manufacturer’s IFU guidelines. 2. failing to ensure surgical staff adhered to acceptable standards of professional practice in surgical attire in the restricted and semi-restricted areas by observations of 3 of 3 (Staff I, J, and W) surgical staff with their surgical masks hanging around the neck and 4 of 4 (Staff H, K, X, and Y) surgical staff wearing cover jackets that were not completely snapped and/or wearing the cover jacket tied around the waist. Observations on 06/02/25 from 2:00 p.m. to 3:00 p.m. in the perioperative surgical restricted areas showed Staff I, J, and W wearing their surgical masks hanging around their necks. Further observations showed Staff H, K, X, and Y wearing their cover jackets unsnapped and hanging loosely and/or their cover jacket tied around the waist. A review of the facility policy titled “Attire for Surgical Procedure Locations”, dated 07/13/23, read in part, “Restricted areas include all operating rooms, the cardiovascular lab, and sterile corridors. Appropriate surgical attire includes scrub top, scrub pants, long-sleeved scrub jacket, and surgical bouffant. Arms should be covered with a long sleeved (cover) jacket in the restricted areas. The long-sleeved jacket should be snapped closed and closely fitted to the body...Masks should not be saved by hanging them around the neck or tucking them into a pocket for future use.” A review of the AORN Guidelines for Perioperative Practice 2021 edition: Guideline for Surgical Attire, read in part, “Surgical attire is worn to provide a high level of cleanliness within the perioperative environment, reducing the patient’s exposure to microorganisms that are shed from the skin and the hair from perioperative personnel and to reduce the patient’s risk for surgical site infections. Cover jackets, if worn, should not be loose fitting and should be buttoned or snapped to prevent the cover jackets from inadvertently contaminating the sterile field when performing circulating tasks.” A review of the AORN Guidelines for Perioperative Practice 2021 edition: Guideline for Sterile Technique, read in part, “Don a clean mask before each procedure and when sterile supplies or sterile personnel are present. Wear a clean surgical mask that covers the mouth, nose, and chin and fit snugly, preventing gaps at the sides of the mask. Masks should be either on or off. Surgical masks are intended to contain and filter droplets from the nasopharynx. The filter portion of the surgical mask harbors bacteria collected from the nasopharyngeal airway and should not be worn hanging from the neck. Surgical masks should be tied securely and discarded after each procedure or when soiled.” On 06/02/25 at 2:15 p.m. Staff G stated the facility followed AORN Perioperative Nursing: Scope and Standards of Practice that included the AORN Guidelines for Perioperative Practice for all surgical services within the facility. On 06/04/25 at 2:35 p.m. Staff N stated the infection control breaches identified by the surveyor had not been identified in Infection Control.”