Okeene Municipal Hospital

“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: 12713 Based on observation and interview, the facility failed to install automatic closing doors in a manner that would retard the spread of smoke to adjacent areas in the event of fire in hazardous areas. Findings: On 05/13/26 a tour of the facility was conducted and the following observation was made: The central supply room that housed large amounts of combustible materials had a dutch door that would not resist the passage of smoke and was not equipped with an automatic self-closing device. On 05/13/26 at 10:50 a.m. the maintenance supervisor acknowledged the problems with the central supply room (hazardous area).”

“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: 12713 Based on record review and interview, the facility failed to maintain and test quarterly, a complete automatic sprinkler system. Findings: On 05/13/26 at 12:10 p.m., the quarterly sprinkler documentation for 2026 was reviewed. The facility could not provide any documentation the quarterly sprinkler inspections for the first quarter of 2026 and the third quarter of 2025 were completed. 2. On 11/25/25 at 12:20 p.m., the Safety Officer and Maintenance Supervisor acknowledged the first quarterly sprinkler of 2026 and the third quarter of 2025 inspections had not been performed.”

“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: 12713 Based on observation and interview, the facility failed to maintain 2 of 4 smoke barrier walls to resist the passage of smoke. Findings: On 05/13/26 between 9:45 a.m. and 12:30 p.m., a tour of the facility was conducted, and the following observations were made: a. the smoke barrier wall by the maintenance office had one unsealed penetration associated with a coax wire and a blue computer wire above the smoke doors in the attic; and b. the smoke barrier wall by the staff lounge had unsealed penetrations associated with electrical conduit and computer wire above the smoke doors in the attic. On 05/13/26 at 11:40 a.m., the maintenance person acknowledged the unsealed penetrations to the smoke walls.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9 This Standard is not met as evidenced by: 12713 Based on observation and interview, the facility failed to maintain smoke barrier doors on 3 of 4 halls to properly seal to resist the passage of smoke. Findings: On 05/13/26 at 10:45 a.m., The smoke doors located on 3 of the 4 halls, did not properly seal to resist the passage of smoke. On 05/13/26 at 11:15 a.m., the Maintenance Supervisor and Safety Officer was interviewed and acknowledged the doors do not properly seal throughout the facility.”

“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: 12713 Based on record review and interview, the facility failed to properly maintain an emergency stop kill switch, remotely located for the generator. Findings: On 05/13/26 at 11:40 a.m., a tour of the facilities generator was conducted. The generator was not equipped with an emergency stop kill switch. In the event of a generator fire/emergency, the facility could not be assured the generator could be powered down remotely. On 05/13/26 at 11:50 a.m., the maintenance supervisor was interviewed and acknowledged the generator was not equipped with the required emergency stop kill switch.”

“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: 41506 Based on observation, record review, and interview, the facility failed to ensure a multi-dose vial when opened in a patient care area became single use and discarded and was not available for other patients in one (Endo#1) of one endoscopy room anesthesia cart. Findings: On 03/10/26 at 2:15 p.m. an observation in Endo #1 anesthesia cart showed an opened multi-dose vial of Labetalol 20 ml available in the cart for other patient use. A review of the CDC Guide to Infection Prevention, September 2016, read in part, “Dedicate multi-dose vials to a single patient whenever possible. If multi-dose vials are used for more than one patient, they should be restricted to a centralized medication area and should not enter the immediate patient treatment area (e.g., operating room, patient room/cubicle). Multi-dose vials opened in a patient care area will be considered single dose and discarded after use.” On 03/10/26 at 2:15 p.m. Staff B stated they were not aware that multi-dose vials when opened in a patient care area must be dedicated to single patient use and discarded after use.”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 41506 Based on record review and interview, the facility failed to ensure the nursing staff developed a nursing care plan for each patient based on assessing all the patient’s care needs and not solely those needs related to the admitting diagnosis for two (Patient #1, #2) of two patients out of 20 patient medical records reviewed for nursing care plans. Findings: A review of Patient #1 medical record read in part, Patient #1 was admitted to the hospital as an inpatient on 03/02/26 with a diagnosis of a hip fracture from a fall. The patient’s medical history showed the patient had a history of coronary artery disease, acid reflux, and anxiety. The current care plan showed the patient only had a documented care plan with goals and treatment plans for falls, skin tissue integrity, and pain. The medical record showed no documented evidence that the patient had a care plan developed for coronary artery disease, acid reflux, or anxiety. A review of Patient #2 medical record read in part, Patient #2 was admitted to the hospital as an inpatient on 02/13/26 with a diagnosis of a post-op hip arthroplasty. The patient’s medical history showed the patient had a history of acid reflux and hypertension. The current care plan showed the patient only had a documented care plan with goals and treatment plans for pain, skin tissue integrity, and falls. The medical record showed no documented evidence that the patient had a care plan developed for acid reflux or hypertension. On 03/11/26 at 10:30 a.m. Staff C stated the nurses developed patient care plans based on the admitting diagnoses and patient care plans were not based on assessing all the patient’s care needs and current diagnoses.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 41506 Based on observation, record review, and interview, the facility failed to ensure staff labeled one of one HLD test strip bottle in the decontamination room with the new expiration date after opening. Findings: On 03/10/26 at 1:40 p.m. an observation of a HLD test strip bottle in the decontamination area showed that the HLD test strip bottle was not labeled with the new expiration date when opened. A review of AORN Guidelines for Perioperative Practice, 2025 edition: Guideline for High-Level Disinfectant, read in part, “Use a test strip specific to the disinfectant before each use of the HLD solution to determine whether the concentration of the active ingredient in the HLD is above or below the minimum effective concentration. Use and store the test strips in accordance with the manufacturer’s IFU.” A review of the test strip manufacturer IFU, read in part, “The test strips have a shelf life of 120 days (4 months) after opening the bottle. The strips should be used within 120 days of opening or before the printed expiration date on the bottle, whichever comes first. Date the bottle with the open date and the new expiration date after opening. Expired test strips can provide inaccurate results and must be discarded upon expiration.” On 03/10/26 at 1:40 p.m. Staff E stated the HLD test strip bottle was not labeled with the new expiration date after opening and they did not remember whether the test strips expired in 3 or 4 months after opening. They stated the manufacturer’s IFU was probably thrown out with the box that contained the test strip bottle. On 03/10/26 at 1:45 p.m. Staff B stated the facility followed the AORN Perioperative Nursing Scope and Standards of Practice and the AORN Guidelines.”