| Sep 20, 2024 | 3 | 0 | 0 | 3 | Read full report |
Deficiencies cited in this report: VENTILATION, LIGHT, TEMPERATURE CONTROLS INFECTION CONTROL PROGRAM INFECTION CONTROL SURVEILLANCE, PREVENTION |
| Jan 12, 2024 | 7 | 0 | 0 | 7 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: INFORMED CONSENT PATIENT RIGHTS: CARE IN SAFE SETTING NURSING SERVICES NURSING CARE PLAN PATIENT CARE ASSIGNMENTS SUPERVISION OF CONTRACT STAFF |
| Apr 28, 2023 | 11 | 0 | 0 | 11 | Read full report |
Deficiencies cited in this report: INSTITUTIONAL PLAN AND BUDGET QUALITY IMPROVEMENT ACTIVITIES FOOD AND DIETETIC SERVICES COMPETENT DIETARY STAFF THERAPEUTIC DIETS PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROGRAM INFECTION CONTROL SURVEILLANCE, PREVENTION |
| Mar 29, 2022 | 0 | 9 | 0 | 9 | Read full report |
Deficiencies cited in this report: Fire Alarm System - Testing and Maintenance Sprinkler System - Maintenance and Testing Portable Fire Extinguishers Corridor - Doors Subdivision of Building Spaces - Smoke Barrie Utilities - Gas and Electric HVAC Gas and Vacuum Piped Systems - Inspection and Electrical Systems - Other |
| Mar 29, 2022 | 30 | 0 | 0 | 30 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: NOTICE OF RIGHTS PATIENT RIGHTS: INFORMED CONSENT PATIENT RIGHTS: PRIVACY AND SAFETY PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT PATIENT RIGHTS: RESTRAINT OR SECLUSION DATA COLLECTION & ANALYSIS NURSING SERVICES STAFFING AND DELIVERY OF CARE NURSING CARE PLAN SUPERVISION OF CONTRACT STAFF ADMINISTRATION OF DRUGS BLOOD TRANSFUSIONS AND IV MEDICATIONS MEDICATION SELF-ADMINISTRATION PHARMACY ADMINISTRATION PHARMACY DRUG RECORDS DELIVERY OF DRUGS UNUSABLE DRUGS NOT USED PERIODIC EQUIPMENT MAINTENANCE FOOD AND DIETETIC SERVICES DIRECTOR OF DIETARY SERVICES THERAPEUTIC DIETS DIETS MAINTENANCE OF PHYSICAL PLANT FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE INFECTION CONTROL PROGRAM INFECTION CONTROL SURVEILLANCE, PREVENTION IC PROFESSIONAL RESPONSIBILITIES POLICIES OPERATING ROOM POLICIES |
| Feb 10, 2022 | 2 | 0 | 0 | 2 | Read full report |
Deficiencies cited in this report: INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL SURVEILLANCE, PREVENTION |
| Jan 10, 2020 | 9 | 0 | 0 | 9 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING RN SUPERVISION OF NURSING CARE NURSING CARE PLAN ADMINISTRATION OF DRUGS VENTILATION, LIGHT, TEMPERATURE CONTROLS INFECTION CONTROL PROGRAM DISCHARGE PLANNING EVALUATION RESPIRATORY CARE SERVICES POLICIES |
| Nov 14, 2019 | 1 | 0 | 0 | 1 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS: CARE IN SAFE SETTING |
Nov 5, 2019 Follow-up to inspection
on 2019-01-22* | 3 | 0 | 0 | 3 | Read full report |
Deficiencies cited in this report: CHIEF EXECUTIVE OFFICER Standard-level Tag for Pharmaceutical Service PHARMACY: REPORTING ADVERSE EVENTS |
Apr 19, 2019 Follow-up to inspection
on 2019-01-22* | 3 | 0 | 0 | 3 | Read full report |
Deficiencies cited in this report: DIRECTOR OF DIETARY SERVICES QUALIFIED DIETITIAN DISPOSAL OF TRASH |
| Jan 25, 2019 | 0 | 23 | 0 | 23 | Read full report |
Deficiencies cited in this report: Building Construction Type and Height Means of Egress Requirements - Other Means of Egress - General Doors with Self-Closing Devices Emergency Lighting Exit Signage Cooking Facilities Fire Alarm System - Initiation Fire Alarm - Control Functions Sprinkler System - Maintenance and Testing Portable Fire Extinguishers Corridor - Doors Subdivision of Building Spaces - Smoke Barrie Utilities - Gas and Electric Operating Features - Other Evacuation and Relocation Plan Smoking Regulations Gas and Vacuum Piped Systems - Other Electrical Systems - Maintenance and Testing Electrical Systems - Essential Electric Syste Electrical Equipment - Other Electrical Equipment - Power Cords and Extens Gas Equipment - Cylinder and Container Storag |
| Jan 22, 2019 | 23 | 0 | 0 | 23 | Read full report |
Deficiencies cited in this report: GOVERNING BODY CONTRACTED SERVICES PATIENT RIGHTS PATIENT RIGHTS: INFORMED CONSENT PATIENT RIGHTS: PRIVACY AND SAFETY PATIENT RIGHTS: CARE IN SAFE SETTING QAPI QUALITY IMPROVEMENT ACTIVITIES NURSING SERVICES RN SUPERVISION OF NURSING CARE ADMINISTRATION OF DRUGS Condition of Participation: Pharmaceutical Se DELIVERY OF DRUGS PHARMACIST SUPERVISION OF SERVICES UNUSABLE DRUGS NOT USED RADIOLOGIC SERVICES PERIODIC EQUIPMENT MAINTENANCE FOOD AND DIETETIC SERVICES COMPETENT DIETARY STAFF THERAPEUTIC DIETS DIETS FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE INFECTION CONTROL PROGRAM |
| Nov 5, 2018 | 14 | 0 | 0 | 14 | Read full report |
Deficiencies cited in this report: GOVERNING BODY CONTRACTED SERVICES PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING QAPI QUALITY IMPROVEMENT ACTIVITIES PATIENT SAFETY NURSING SERVICES RN SUPERVISION OF NURSING CARE SUPERVISION OF CONTRACT STAFF Condition of Participation: Pharmaceutical Se PHARMACIST SUPERVISION OF SERVICES OUTPATIENT SERVICES STANDARD TAG FOR OUTPATIENT SERVICES |
Jul 28, 2016 Follow-up to inspection
on 2015-12-18* | 0 | 6 | 0 | 6 | Read full report |
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available |
Apr 8, 2016 Follow-up to inspection
on 2015-12-18* | 0 | 20 | 0 | 20 | Read full report |
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD |
Apr 8, 2016 Follow-up to inspection
on 2015-12-22* | 23 | 0 | 0 | 23 | Read full report |
Deficiencies cited in this report: GOVERNING BODY CONTRACTED SERVICES PATIENT RIGHTS: REVIEW OF GRIEVANCES PATIENT RIGHTS: EXERCISE OF RIGHTS PATIENT RIGHTS: INFORMED DECISION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION QUALITY IMPROVEMENT ACTIVITIES PATIENT SAFETY STAFFING AND DELIVERY OF CARE NURSING CARE PLAN ADMINISTRATION OF DRUGS ORDERS FOR DRUGS AND BIOLOGICALS CONTENT OF RECORD: ORDERS DATED & SIGNED PHARMACY DRUG RECORDS DELIVERY OF DRUGS PHARMACIST SUPERVISION OF SERVICES ADEQUACY OF LABORATORY SERVICES PHYSICAL ENVIRONMENT INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROFESSIONAL INFECTION CONTROL PROGRAM No Description Available |
| Dec 22, 2015 | 47 | 0 | 0 | 47 | Read full report |
Deficiencies cited in this report: GOVERNING BODY MEDICAL STAFF - SELECTION CRITERIA CONTRACTED SERVICES PATIENT RIGHTS: INFORMED CONSENT PATIENT RIGHTS: PERSONAL PRIVACY PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION QAPI DATA COLLECTION & ANALYSIS QUALITY IMPROVEMENT ACTIVITIES PATIENT SAFETY QAPI EXECUTIVE RESPONSIBILITIES MEDICAL STAFF PERIODIC APPRAISALS MEDICAL STAFF RESPONSIBILITIES - H&P STAFFING AND DELIVERY OF CARE RN SUPERVISION OF NURSING CARE NURSING CARE PLAN ADMINISTRATION OF DRUGS FORM AND RETENTION OF RECORDS PROTECTING PATIENT RECORDS MEDICAL RECORD SERVICES CONTENT OF RECORD: ORDERS DATED & SIGNED CONTENT OF RECORD: INFORMED CONSENT CONTENT OF RECORD: ORDERS,NOTES,REPORTS Standard-level Tag for Pharmaceutical Service PHARMACY ADMINISTRATION PHARMACY DRUG RECORDS DELIVERY OF DRUGS PHARMACIST SUPERVISION OF SERVICES SECURE STORAGE UNUSABLE DRUGS NOT USED AFTER-HOURS ACCESS TO DRUGS SAFETY FOR PATIENTS AND PERSONNEL PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT DISPOSAL OF TRASH FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROGRAM IMPLEMENTATION OF A DISCHARGE PLAN STAFF EDUCATION ORGANIZATION OF ANESTHESIA SERVICES POST-ANESTHESIA EVALUATION OUTPATIENT SERVICES OUTPATIENT SERVICES PERSONNEL |
| Dec 18, 2015 | 0 | 55 | 0 | 55 | Read full report |
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available Means of Egress - General LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD |
| Sep 25, 2015 | 0 | 44 | 0 | 44 | Read full report |
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available Multiple Occupancies - Contiguous Non-Health Multiple Occupancies - Construction Type No Description Available No Description Available LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD |
| Sep 25, 2015 | 29 | 0 | 0 | 29 | Read full report |
Deficiencies cited in this report: GOVERNING BODY CARE OF PATIENTS - PRACTITIONERS PATIENT RIGHTS: GRIEVANCES PATIENT RIGHTS: REVIEW OF GRIEVANCES PATIENT RIGHTS: INFORMED DECISION PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS PATIENT RIGHTS: RESTRAINT OR SECLUSION QAPI DATA COLLECTION & ANALYSIS QUALITY IMPROVEMENT ACTIVITIES PATIENT SAFETY QAPI EXECUTIVE RESPONSIBILITIES PROVIDING ADEQUATE RESOURCES STAFFING AND DELIVERY OF CARE RN SUPERVISION OF NURSING CARE ADMINISTRATION OF DRUGS CONTENT OF RECORD: ORDERS DATED & SIGNED SECURE STORAGE PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE VENTILATION, LIGHT, TEMPERATURE CONTROLS INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROGRAM No Description Available INTEGRATION OF OUTPATIENT SERVICES INTEGRATION OF EMERGENCY SERVICES QUALIFIED EMERGENCY SERVICES PERSONNEL |
Jun 4, 2015 Follow-up to inspection
on 2015-02-05* | 0 | 1 | 0 | 1 | Read full report |
Deficiencies cited in this report: No Description Available |
Jun 4, 2015 Follow-up to inspection
on 2015-02-05* | 2 | 0 | 0 | 2 | Read full report |
Deficiencies cited in this report: MAINTENANCE OF PHYSICAL PLANT FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE |
| Feb 5, 2015 | 0 | 6 | 0 | 6 | Read full report |
Deficiencies cited in this report: No Description Available No Description Available No Description Available LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD |
| Feb 5, 2015 | 3 | 0 | 0 | 3 | Read full report |
Deficiencies cited in this report: PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT LIFE SAFETY FROM FIRE |
Jan 15, 2015 Follow-up to inspection
on 2014-04-01* | 5 | 0 | 0 | 5 | Read full report |
Deficiencies cited in this report: DIRECTOR OF DIETARY SERVICES DIETS MAINTENANCE OF PHYSICAL PLANT VENTILATION, LIGHT, TEMPERATURE CONTROLS INFECTION CONTROL PROGRAM |
Aug 21, 2014 Follow-up to inspection
on 2014-04-01* | 0 | 7 | 0 | 7 | Read full report |
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available |
Aug 21, 2014 Follow-up to inspection
on 2014-04-01* | 19 | 0 | 0 | 19 | Read full report |
Deficiencies cited in this report: QAPI QUALITY IMPROVEMENT ACTIVITIES QAPI PERFORMANCE IMPROVEMENT PROJECTS DELIVERY OF DRUGS SECURE STORAGE ACCESS TO LOCKED AREAS FOOD AND DIETETIC SERVICES DIRECTOR OF DIETARY SERVICES No Description Available DIETS PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT EMERGENCY GAS AND WATER FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE VENTILATION, LIGHT, TEMPERATURE CONTROLS INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROGRAM SURGICAL SERVICES OPERATING ROOM POLICIES |
| Apr 1, 2014 | 42 | 0 | 0 | 42 | Read full report |
Deficiencies cited in this report: GOVERNING BODY PATIENT RIGHTS PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING PATIENT RIGHTS: PERSONAL PRIVACY PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT NURSING SERVICES STAFFING AND DELIVERY OF CARE RN SUPERVISION OF NURSING CARE NURSING CARE PLAN ADMINISTRATION OF DRUGS ORGANIZATION AND STAFFING CONTENT OF RECORD: ORDERS DATED & SIGNED CONTENT OF RECORD: HISTORY & PHYSICAL CONTENT OF RECORD: ORDERS,NOTES,REPORTS CONTENT OF RECORD: DISCHARGE SUMMARY Standard-level Tag for Pharmaceutical Service DELIVERY OF DRUGS SECURE STORAGE UNUSABLE DRUGS NOT USED POTENTIALLY INFECTIOUS BLOOD/BLOOD PRODUCTS FOOD AND DIETETIC SERVICES ORGANIZATION QUALIFIED DIETITIAN COMPETENT DIETARY STAFF No Description Available THERAPEUTIC DIETS DIETS THERAPEUTIC DIET MANUAL PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT EMERGENCY GAS AND WATER DISPOSAL OF TRASH FACILITIES FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROFESSIONAL INFECTION CONTROL PROGRAM SURGICAL SERVICES OPERATING ROOM POLICIES HISTORY AND PHYSICAL REQUIRED OPERATING ROOM EQUIPMENT |
| Apr 1, 2014 | 0 | 28 | 0 | 28 | Read full report |
Deficiencies cited in this report: No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available No Description Available LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD LIFE SAFETY CODE STANDARD |
