Choctaw Memorial Hospital

“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: 46363 Based on record review and interview, the facility failed to develop a comprehensive emergency preparedness plan. This deficient practice has the potential to affected 8 of 8 residents, who currently resided in the facility, as identified by the Safety Director on 01/08/26. Findings: On 01/08/26 at 11:45 the facilities emergency preparedness plan was reviewed and did not meet all the requirements for a comprehensive emergency preparedness program. On 01/08/26 at 11:45 the facilities emergency preparedness plan was reviewed and the Safety Director was interviewed. The Safety Director acknowledged the emergency preparedness plan was not complete.”

“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: 46363 Based on observation and interview, the facility failed to perform monthly inspections on 2 portable fire extinguishers located on 1 hall (ER Hall). This deficient practice affected approximately 8 of 8 residents who resided in the facility, as identified by the Safety Director on 01/08/26. Findings: On 01/08/26 from 12:35 p.m. to 3:15 p.m. a tour of the facility was conducted and 2 portable fire extinguishers had no monthly inspections. 1 located in the riser room on ER Hall and 1 located in electrical room on ER Hall. On 01/08/26 from 12:35 p.m. to 3:15 p.m. the maintenance supervisor was present during a tour of the facility and was interviewed. The maintenance supervisor acknowledged the 2 portable fire extinguishers were missing monthly inspections.”

“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: 46363 Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke located on 2 Halls (East and X Ray Halls). This deficient practice had the potential to affect 8 of 8 residents, who resided in the facility, as identified by the Safety Director on 01/08/26. Findings: On 12/17/25 from 12:35 p.m. to 3:15 p.m. a tour of the facility was conducted, and the following observations were made: a. Located on the X Ray Hall, the door to the x ray storage closet was not closing and latching properly. b. Located on East Hall, the door to the housekeeping closet had a gap at the top of the door. c. Located on East Hall, the door to the IT tech office had a gap at the top of the door. d. Located on East Hall, the door to the Radiology Director office had a gap at the top of the door. On 12/17/25 from 12:35 p.m. to 3:15 p.m. the maintenance supervisor was present during the tour of the facility and was interviewed. The maintenance supervisor acknowledged the problems with the corridor doors.”

“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 assure the minimum required number of fire drills were conducted within the past year. This had the potential to affect 8 of 8 residents who resided in the facility as identified by the administrator on 01/08/26. Findings: On 01/08/26 a review of the facilities fire drill documents were reviewed from January 2025 to January 2026 and the fire drills from quarter 1, quarter 2 and quarter 3 of 2025 were not made available. On 01/08/26 a review of the facilities fire drill documents were reviewed from January 2025 to January 2026 and the maintenance supervisor was interviewed. The maintenance supervisor acknowledged the missing fire drills for quarter 1, quarter 2 and quarter 3 of 2025.”

“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 could affect 8 of 8 residents who resided in the facility, as identified by the Safety Director on 01/08/26. Findings: On 01/08/26 from 12:35 p.m. to 3:15 p.m. a tour of the facility was conducted and the facilities generator did not have a remote emergency stop button (kill switch). On 01/08/26 from 12:35 p.m. to 3:15 p.m. the maintenance supervisor was present during a tour of the facility and was interviewed. The maintenance supervisor acknowledged that the generator did not have a remote stop button (kill switch).”

“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: 46363 Based on observation and interview, the facility failed to ensure the electrical system was properly installed and maintained in the kitchen. This practice has the potential to affected 8 of 8 residents, who currently reside in the facility, as identified by the Safety Director on 01/08/26. Findings: On 01/08/26 from 12:35 p.m. to 3:15 p.m. a tour of the facility was conducted and two outlets, one between the grill and the sink and one on the serving bar area, were found within six feet of a water source. The outlets were not ground fault circuit interrupter outlets (GFCI). On 01/08/26 from 12:35 p.m. to 3:15 p.m. the maintenance supervisor was present during a tour of the facility and was interviewed. The maintenance supervisor acknowledged the 2 outlets were not ground fault interrupter outlets (GFCI).”

“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: 32662 Based on observation, record review and interview, facility ’ s registered nurses failed to conduct complete and accurate assessment on patients with impaired skin integrity and failed to provide treatment as prescribed by the patient ’ s physician in two of 8 sampled patients. Patients #s 1 and 5 Findings: Patient #1 On 09/15/2025 at 10:00 a.m. Patient #1 was observed in bed with side rails up and oxygen in place at three liters / minute via nasal canula. The patient was discharged for home and awaiting transportation with spouse at bedside. The Facility ’ s Chief Nursing Officer and Registered Nurse (52B) examined the patient ’ s skin. Observation showed the patient ’ s buttocks and coccygeal area with excoriated skin. There was no evidence of dressing / treatment in place to the patient ’ s excoriated areas. Review of the patient ’ s clinical record (demographic data), showed the patient was admitted to the facility on 09/14/2025 with diagnosis of recurrent urinary tract infection, decreased appetite and weakness. Review of the patient ’ s nursing emergency room skin integrity assessment completed on 09/14/2025 at 11:55 a.m. showed the following documentation: “skin integrity risk assessment completed, no skin assessment integrity risk identified.” Review of the Patient Initial Interview document, dated 09/14/2025 at 4:15 p.m. showed the following entry “Medical history integument; healing bruising to bil upper ext.” Review of physician ’ s progress notes (physical examination) showed the following documentation: “Skin warm and dry. Normal skin color” Review of a completed discharge summary dated 09/15/2025 at 09:18 a.m. showed the following documentation: “Skin integrity intact” During an Interview on 09/15/2025 at 10:05 a.m. the patient ’ s spouse stated, the patient is discharged to home. While at home prior to coming to the hospital while being pulled up in bed, the skin to the patient ’ s buttock came off. While at home the spouse dressed it but did not do it while the patient was in the hospital. During an interview on 09/15/2025 at 2:30 p.m. Registered Nurse (55E) assigned to the patient stated, a Foley catheter was inserted on the patient while in the emergency room with redness to the patient ’ s buttocks observed. The patient ’ s buttocks were reddened as a result of a soaked diaper, but the redness was not documented, neither was the excoriation of the patient ’ s buttocks and coccygeal areas. Patient #5 A review of the clinical record (demographic data) showed the patient was admitted to the facility on 09/12/2025 with admitting diagnosis of cellulitis of right calf, diabetes mellitus and insect bite. Review of the patient ’ s record showed a history and physical dictated on 09/12/2025 by the physician assistant at 7:00 pm and signed by the physician on 09/15/2025 with the following entry: “Chief complaints: Complains of pain in calf with edema and serosanguineous drainage, necrosis to the middle of the wound.” Plan included admission to the hospital, Hibiclens shower daily, warm compresses to left lower inner calf every 4 hours and Invanx I gram intravenous every 24 hours. Review of the patient ’ s clinical record showed the following verbal order from the patient ’ s physician: 09/13/2025 at 8:05 pm; “Apply warm compresses to the right inner calf q 4 hours.” Review of the patient ’ s clinical record (nurses progress notes) showed warm compresses were applied to the patient ’ s right inner calf on the following days and times: 09/13/2025 at 1:08 pm, 7:05 pm and 10:03 pm 09/14/2025 at 7:30 pm. There was no further documentation in the patient’s record that the physician ’ s order of applying warm compresses to the patient ’ s right inner calf every 4 hour was carried out. During an interview on 09/16/2025 at 2:37 p.m. with Licensed Practical Nurse ( 54D) who was assigned to the patient on the day shift on Sunday 09/14/2025, Monday 09/15/2025 and Tuesday 09/16/2025 , the nurse stated “I did not give it today because the patient had a surgical consult but I gave it on the 15th right before breakfast, at lunch and at supper but I did not document.””

“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: 32662 Based on observation and interview, the facility failed to maintain a clean and sanitary environment for one of one storage room, one of one respiratory suite, one of one pharmacy, and one of one surgical suite observed. Findings: STORAGE ROOM Observation on 09/15/2025 at 11:20 a.m. of a storage room near the outpatient suite revealed three boxes of pillows stored directly on the floor and not on pallets to prevent cross contamination. During an Interview on 09/15/2025 Outpatient Registration Personnel (56F) stated housekeeping puts the stuff in the boxes on the floor. RESPIRATORY SUITE Observation on 09/15/ 2025 at 12:00 p.m. of the facility ’ s respiratory suite, room which stored clean ventilators prepared for patients’ usage showed the ceiling tiles directly above the ventilators with brown water stains and a hole in one of the ceiling tiles. On 09/15/2025 at 12:15 p.m. Registered Nurse (52 B) summoned the Facility ’ s Maintenance Supervisor to the room. The maintenance supervisor removed two of the water-stained ceiling tiles which showed an accumulation of blackened material. Facility ’ s Maintenance Supervisor (57G) stated “Those are mildew, but it is dry. “ During an Interview on 09/15/2025 at 12:0 8 p.m. the respiratory therapist stated “the water stains to the ceiling tiles have been there a long time (months.)” PHARMACY During a tour of the facility ’ s pharmacy on 09/17/2025 at 8:40 a.m. with the Pharmacy Supervisor, the following items were observed stored directly on the floor in boxes: Five boxes of Sodium Chloride 1000 mis with potassium, and two boxes’ of 1000 CCs Normal Saline. Observation on 9/17/2025 at 8:42 a.m. the bathroom located in the pharmacy suite flooring tiles with brown stain from around the toilet to the handwashing sink. Registered Nurse (52B) stated “It looks moldy.” UNSECURED MEDICATIONS Observation on 09/15/2025 11:18 a.m. of the facility ’ s outpatient area (examination room #1) showed three vials of intravenous Benadryl medication (lot # 6035012) stored in an unlocked drawer. The drawer and door were opened, and staff were not present in the area. The medication was not in view of direct care staff. During an nterview on 09/15/2025 at 11:19 a.m., Registered Nurse (52B) stated the medications were brought over by emergency room staff and left unsecured.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 32662 Based on observation, record review and interview, the facility failed to implement its policy and procedure to ensure staff participate in quarterly fire drills in 5 of 8 staff record reviewed: Registered Nurse 51A, Registered Nurse (52C), Registered Nurse (58H), Licensed Practical Nurse (54 D), and Dietary Supervisor (59I). On 09/15/2025 during tour of the facility, the following staff were observed on various units providing care and services to patients: Registered Nurse 51A, Registered Nurse (52C), Registered Nurse (58H), Licensed Practical Nurse (54 D), and Dietary Supervisor (59I). Review of the facility ’ s life safety plan (not dated) directs staff as follows: “Fire drills are conducted once per shift per quarter announced and unannounced. Drills are reviewed for opportunities for improvement; drills are conducted by the Safety Manager and documented as well as sign in sheet.” Review of fire drill logs provided by facility ’ s Safety Officer showed the most current drill was conducted 06/13/2025. Review of the log showed no documentation that the following staff participated in the fire drill conducted on 06/13/2025: Registered Nurse 51A, Registered Nurse (52C), Registered Nurse (58H), Licensed Practical Nurse (54 D), and Dietary Supervisor (59I). The facility ’ s Safety Officer reviewed the log with the Surveyor and confirmed that the above staff did not participate in fire drill held on 6/13/2025. During an interview on 09/16/2025 at 12:30 p.m. the facility ’ s Safety Officer stated, “I did not do fire drills for January and March, I am lacking in drills for this year.””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 32662 Based on observation and interview, the facility failed to ensure supplies stored in 1 of 3 emergency crash carts and outpatient area for patients care and services were not expired. Findings: An observation in facility ’ s nurses’ station, on 09/15/2025 at10:12 a.m. in the presence of Facility ’ s Chief Nursing Officer showed the following supplies stored in the emergency crash cart were expired: Two intravenous lines, Lot # 32134582 expired on 3/30/2025 Two intravenous starter kit, Lot # 2J3185 expired on 4/24/2025 One intravenous starter kit, Lot # 2J31112expired on 4/24/2025 10 needles with syringes attached 0.75 inches, lot # 2214515 expired 7/31/2025 Review of the log for the crash cart revealed documentation that it was last checked on 09/15/2025 and staff did not identify the expired supplies. During an Interview on 09/15/2025 at 10:20 a.m. the facility ’ s Chief Nursing Officer (51A) stated, “the cart is checked by the charge nurse every shift, but the lock for the cart is not broken when checked and pharmacy checks it monthly.” During an Interview on 09/15/2025 at 10:29 a.m. the facility ’ s Charge Nurse stated ’ We don’t break the lock; we check the top. We only break the lock once monthly.” OUTPATIENT Observation on 09/15/2025 at 11:16 a.m. of the facility ’ s outpatient suite storage drawers showed 16 syringes with needles attached (lot # 7268010) expired on 9/30/2022. Catheter stabilization device (Lot number JUDxF468) expired 9/28/2022. Two bottles povidone Iodine lot # 208JA 8 expired 1/22 During an interview on 09/15/2025 at 11:20 a.m. Registered Nurse (52 B) stated things are brought from the emergency room to outpatient and purchasing staff do not check the drawer for expired supplies.”

“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: 32662 BCLS EMERGENCY TRAINING Based on observation, record review and interview, the facility failed to ensure direct care staff participate in basic cardiac life support training in 2 of 7 staff ’ s personnel and training records reviewed. Registered nurse #s 51A and 53C. On 09/15/2025 - 09/17/ 2027 (duration of the survey) Registered nurse (51A) was observed in the facility. Review of Registered Nurse (51A ’ s) personnel and training record showed the most recent basic cardiac life support training on file was dated 09/12/2022 - 09/2024. There was no evidence of a current certificate which was not expired. Registered Nurse (#53C) On 09/15/2025 at 10:10 a.m. Registered Nurse (53C) was observed on the medical surgical unit of the facility providing care and services to patients. Review of Registered Nurse (53C ’ s) personnel and training record showed the most recent basic cardiac life support training on file was dated 09/13/2022 - 09/2024. There was no evidence of a current certificate which was not expired. During an Interview on 09/16/2025 at 11:15 a.m. the facility ’ s Chief Nursing Officer stated the facility is aware of staff having expired basic cardiac life support training.”