Winkler County Memorial Hospital

“A life safety code (LSC) survey was conducted on site on 06/25/2025. An entrance conference was held for the CEO, Facilty Manager, Security Officer, and Compliance Officer on 06/25/2025 to discuss the purpose of the LSC survey, and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. An LSC exit conference was conducted on 06/25/2025 in the hospital. In attendance were the CEO, Facility Manager, Security Officer, and Compliance Officer. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“General Requirements - Other CFR(s): NFPA 101 General Requirements - Other List in the REMARKS section any LSC Section 18.1 and 19.1 General 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. This Standard is not met as evidenced by: 50678 Based on observation, the facility failed to meet the requirement of NFPA-5000 as indicated below. Smoke and Fire Walls should be labeled per NFPA-5000, Based on observation, the facility failed to meet the reqquirement of ASHRE 170 as indicated below. The Isolation Room requires a 10’ Exhaust per ASHRE 170 2008.”

“Means of Egress Requirements - Other CFR(s): NFPA 101 Means of Egress Requirements - Other List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress 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. 18.2, 19.2 This Standard is not met as evidenced by: 50678 Based on observation, the facility failed to provide adequate documentation to denote facility Life Safety Plans denoting rated walls, Smoke Barrier Walls and Egress Routes per NFPA-101”

“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: 50678 Based on observations at the time of the inspection, the facility’s Smoke Barriers and Rated Wall Assemblies had applied (“Scabbed-On”) sheetrock not installed per ASTM/UL rated assembly in multiple locations. NFPA-101 19.3.7.3.? Smoke Barrier Walls had opening which were not sealed. NFPA-101 19.3.7.3? Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum ½-hour fire resistance rating, unless otherwise permitted by one of the following: (1)?This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a)?Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b)?Not less than two separate smoke compartments shall be provided on each floor, (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.”

“Building Services - Other CFR(s): NFPA 101 Building Services - Other List in the REMARKS section any LSC Section 18.5 and 19.5 Building Services 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. This Standard is not met as evidenced by: 50678 At the time of inspection, the inspector was unable verify Final Filters at the Emergency Room Air Handling Unit. (See Reference Below) NFPA-90A 2-2.2 Air Cleaners and Air Filters. 2-2.2.1 Electrostatic air cleaners shall be listed in accordance with UL 867, Standard for Safety Electrostatic Air Cleaners, and shall be installed in conformance with the conditions of the manufacturer’s listing. TAC 133,169(d) Figure: 25 TAC §133.169(d) Page 1 of 1 TABLE 4 FILTER EFFICIENCIES FOR CENTRAL VENTILATION AND AIR CONDITIONING SYSTEMS General procedure operating rooms, delivery rooms, nurseries, critical care units, patient care areas and treatment, diagnostic and related areas Number of Filter Beds - 2 Filter Bed #1 (Percent) 25, (Merv) 7 Filter Bed #2 (Percent) 90, (Merv) 14”

“Draperies, Curtains, and Loosely Hanging Fabr CFR(s): NFPA 101 Draperies, Curtains, and Loosely Hanging Fabrics Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall. 18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1 This Standard is not met as evidenced by: 50678 During observations at the time of the inspection, the Inspector was unable to identify Flame Spread and Smoke Development rating on Cubical Curtains and Furnishings. Hospital does not have a purchasing policy regarding FF&E. NFPA- 101 10.3.1* Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall meet the flame propagation performance criteria contained in NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. NFPA-101 19.7.5.1* Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1 (see 19.3.5.11), and the following also shall apply: (1)?Such curtains shall include cubicle curtains.”

“Upholstered Furniture and Mattresses CFR(s): NFPA 101 Upholstered Furniture and Mattresses Newly introduced upholstered furniture meets Class I or char length, and heat release criteria in accordance with 10.3.2.1 and 10.3.3, unless the building is fully sprinklered. Newly introduced mattresses shall meet char length and heat release criteria in accordance with 10.3.2.2 and 10.3.4, unless the building is fully sprinklered. Upholstered furniture and mattresses belonging to nursing home residents do not have to meet these requirements as all nursing homes are required to be fully sprinklered. Newly introduced upholstered furniture and mattresses means purchased on or after the LSC final rule effective date. 18.7.5.2, 18.7.5.4, 19.7.5.2, 19.7.5.4 This Standard is not met as evidenced by: 50678 At the time of the inspection, and based on document and material review, the Inspector was unable to identify Flame Spread and Smoke Development rating on Furnishings. Hospital does not have a purchasing policy regarding FF&E. NFPA-101 19.7.5.2? Newly introduced upholstered furniture within health care occupancies shall comply with one of the following provisions, unless otherwise provided in 19.7.5.3:”