| Jul 16, 2024 | 37 | 0 | 0 | 37 | Read full report |
Deficiencies cited in this report: GOVERNING BODY MEDICAL STAFF CONTRACTED SERVICES CONTRACTED SERVICES PATIENT RIGHTS PATIENT RIGHTS: NOTICE OF RIGHTS PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION PATIENT RIGHTS: EXERCISE OF RIGHTS PATIENT RIGHTS: INFORMED CONSENT PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT QAPI DATA COLLECTION & ANALYSIS QUALITY IMPROVEMENT ACTIVITIES QAPI GOVERNING BODY, STANDARD TAG QAPI EXECUTIVE RESPONSIBILITIES MEDICAL STAFF MEDICAL STAFF CREDENTIALING MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY NURSING SERVICES RN SUPERVISION OF NURSING CARE ADMINISTRATION OF DRUGS Condition of Participation: Pharmaceutical Se DELIVERY OF DRUGS SECURE STORAGE PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT LIFE SAFETY FROM FIRE FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE VENTILATION, LIGHT, TEMPERATURE CONTROLS INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROFESSIONAL INFECTION CONTROL PROGRAM INFECTION CONTROL SURVEILLANCE, PREVENTION SURGICAL PRIVILEGES OPERATING ROOM POLICIES |
| Jul 10, 2024 | 0 | 22 | 5 | 27 | Read full report |
Deficiencies cited in this report: Develop EP Plan, Review and Update Annually Plan Based on All Hazards Risk Assessment Policies/Procedures for Sheltering in Place EP Training Program EP Testing Requirements Building Construction Type and Height Means of Egress - General Egress Doors Illumination of Means of Egress Emergency Lighting Hazardous Areas - Enclosure Cooking Facilities Fire Alarm System - Installation Fire Alarm System - Testing and Maintenance Fire Alarm System - Out of Service Sprinkler System - Installation Sprinkler System - Maintenance and Testing Portable Fire Extinguishers Subdivision of Building Spaces - Smoke Barrie Subdivision of Building Spaces - Smoke Barrie HVAC Elevators Evacuation and Relocation Plan Fire Drills Portable Space Heaters Electrical Systems - Essential Electric Syste Electrical Equipment - Power Cords and Extens |
| May 22, 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 PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT RN SUPERVISION OF NURSING CARE INFECTION CONTROL SURVEILLANCE, PREVENTION |
| Apr 17, 2024 | 1 | 0 | 0 | 1 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS: CARE IN SAFE SETTING |
| Dec 14, 2023 | 3 | 0 | 0 | 3 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: GRIEVANCES PATIENT RIGHTS: CARE IN SAFE SETTING |
| Jul 10, 2023 | 1 | 0 | 0 | 1 | Read full report |
Deficiencies cited in this report: MAINTENANCE OF PHYSICAL PLANT |
| Feb 9, 2022 | 1 | 0 | 0 | 1 | Read full report |
Deficiencies cited in this report: COVID-19 Vaccination of Facility Staff |
| Oct 12, 2021 | 2 | 0 | 0 | 2 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING |
| Jul 13, 2021 | 1 | 0 | 0 | 1 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS: GRIEVANCES |
| Apr 14, 2021 | 9 | 0 | 0 | 9 | Read full report |
Deficiencies cited in this report: PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT EMERGENCY GAS AND WATER LIFE SAFETY FROM FIRE STANDARD: BUILDING SAFETY FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE VENTILATION, LIGHT, TEMPERATURE CONTROLS INFECTION CONTROL PROGRAM OPO AGREEMENT |
| Apr 14, 2021 | 0 | 20 | 3 | 23 | Read full report |
Deficiencies cited in this report: Subsistence Needs for Staff and Patients Roles Under a Waiver Declared by Secretary EP Training Program Egress Doors Protection - Other Vertical Openings - Enclosure Hazardous Areas - Enclosure Fire Alarm System - Installation Fire Alarm System - Initiation Fire Alarm System - Out of Service Sprinkler System - Installation Sprinkler System - Maintenance and Testing Sprinkler System - Out of Service Portable Fire Extinguishers Corridor - Doors Subdivision of Building Spaces - Smoke Barrie Smoke Barrier Door Glazing HVAC Fire Drills Maintenance, Inspection and Testing - Doors Portable Space Heaters Electrical Systems - Receptacles Electrical Systems - Essential Electric Syste |
| Jan 11, 2021 | 5 | 0 | 0 | 5 | Read full report |
Deficiencies cited in this report: PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT LIFE SAFETY FROM FIRE FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE VENTILATION, LIGHT, TEMPERATURE CONTROLS |
| Dec 10, 2020 | 2 | 0 | 0 | 2 | Read full report |
Deficiencies cited in this report: INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROGRAM |
| Apr 15, 2020 | 3 | 0 | 0 | 3 | Read full report |
Deficiencies cited in this report: INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROFESSIONAL INFECTION CONTROL PROGRAM |
| Mar 27, 2018 | 3 | 0 | 0 | 3 | Read full report |
Deficiencies cited in this report: PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE |
Oct 11, 2017 Follow-up to inspection
on 2017-06-28* | 1 | 0 | 0 | 1 | Read full report |
Deficiencies cited in this report: ORDERS FOR DRUGS AND BIOLOGICALS |
| Jun 28, 2017 | 34 | 0 | 0 | 34 | Read full report |
Deficiencies cited in this report: GOVERNING BODY CONSULTATION WITH MEDICAL STAFF INSTITUTIONAL PLAN AND BUDGET PATIENT RIGHTS PATIENT RIGHTS: NOTICE OF RIGHTS PATIENT RIGHTS: GRIEVANCES PATIENT RIGHTS: CARE IN SAFE SETTING QAPI DATA COLLECTION & ANALYSIS QUALITY IMPROVEMENT ACTIVITIES PATIENT SAFETY MEDICAL STAFF CREDENTIALING NURSING SERVICES RN SUPERVISION OF NURSING CARE NURSING CARE PLAN PATIENT CARE ASSIGNMENTS ADMINISTRATION OF DRUGS FOOD AND DIETETIC SERVICES DIRECTOR OF DIETARY SERVICES THERAPEUTIC DIETS PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT EMERGENCY GAS AND WATER LIFE SAFETY FROM FIRE FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE VENTILATION, LIGHT, TEMPERATURE CONTROLS INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROGRAM No Description Available SURGICAL SERVICES ORGANIZATION OF SURGICAL SERVICES SURGICAL PRIVILEGES OPERATING ROOM POLICIES HISTORY AND PHYSICAL |
| Jun 27, 2017 | 0 | 19 | 0 | 19 | Read full report |
Deficiencies cited in this report: General Requirements - Other Multiple Occupancies - Construction Type Means of Egress - General Stairways and Smokeproof Enclosures Illumination of Means of Egress Protection - Other Hazardous Areas - Enclosure Fire Alarm System - Testing and Maintenance Portable Fire Extinguishers Corridor - Doors Subdivision of Building Spaces - Smoke Barrie Subdivision of Building Spaces - Smoke Barrie Fire Drills Portable Space Heaters Construction, Repair, and Improvement Operati Electrical Systems - Essential Electric Syste Electrical Equipment - Other Electrical Equipment - Power Cords and Extens Gas Equipment - Cylinder and Container Storag |
| May 8, 2017 | 7 | 0 | 0 | 7 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS: PERSONAL PRIVACY PATIENT RIGHTS: CARE IN SAFE SETTING PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT EMERGENCY GAS AND WATER VENTILATION, LIGHT, TEMPERATURE CONTROLS INFECTION CONTROL PROGRAM |
| Jan 23, 2017 | 3 | 0 | 0 | 3 | Read full report |
Deficiencies cited in this report: INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROFESSIONAL INFECTION CONTROL PROGRAM |
Jun 9, 2014 Follow-up to inspection
on 2013-10-07* | 1 | 0 | 0 | 1 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS: CARE IN SAFE SETTING |
| May 7, 2014 | 5 | 0 | 0 | 5 | Read full report |
Deficiencies cited in this report: NURSING SERVICES ORGANIZATION OF NURSING SERVICES DIRECTOR OF DIETARY SERVICES THERAPEUTIC DIETS THERAPEUTIC DIET MANUAL |
| Oct 10, 2013 | 0 | 40 | 0 | 40 | 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 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 |
| Oct 10, 2013 | 20 | 0 | 0 | 20 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS: NOTICE OF RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING USE OF RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION QAPI DATA COLLECTION & ANALYSIS QAPI EXECUTIVE RESPONSIBILITIES PROVIDING ADEQUATE RESOURCES 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 TRANSFER OR REFERRAL ORGAN, TISSUE, EYE PROCUREMENT STAFF EDUCATION DEATH RECORD REVIEWS |
| Oct 7, 2013 | 7 | 0 | 0 | 7 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: NOTICE OF RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT USE OF RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION |
| Aug 6, 2013 | 5 | 0 | 0 | 5 | Read full report |
Deficiencies cited in this report: EMERGENCY SERVICES EMERGENCY LABORATORY SERVICES EMERGENCY SERVICES INTEGRATION OF EMERGENCY SERVICES EMERGENCY SERVICES POLICIES |
Feb 4, 2013 Follow-up to inspection
on 2012-11-19* | 0 | 1 | 0 | 1 | Read full report |
Deficiencies cited in this report: No Description Available |
Jan 16, 2013 Follow-up to inspection
on 2012-11-15* | 1 | 0 | 0 | 1 | Read full report |
Deficiencies cited in this report: PHYSICAL ENVIRONMENT |
| Nov 19, 2012 | 0 | 58 | 0 | 58 | 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 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 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 |
| Nov 15, 2012 | 22 | 0 | 0 | 22 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS: NOTICE OF RIGHTS PATIENT RIGHTS: GRIEVANCES PATIENT RIGHTS: REVIEW OF GRIEVANCES PATIENT RIGHTS: INFORMED CONSENT PATIENT RIGHTS: PERSONAL PRIVACY PATIENT RIGHTS: RESTRAINT OR SECLUSION QAPI DATA COLLECTION & ANALYSIS QUALITY IMPROVEMENT ACTIVITIES QAPI EXECUTIVE RESPONSIBILITIES STAFFING AND DELIVERY OF CARE CONTENT OF RECORD: ORDERS DATED & SIGNED UNUSABLE DRUGS NOT USED DIRECTOR OF DIETARY SERVICES DIETS PHYSICAL ENVIRONMENT MAINTENANCE OF PHYSICAL PLANT FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE VENTILATION, LIGHT, TEMPERATURE CONTROLS INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROFESSIONAL INFECTION CONTROL PROGRAM |
| Jul 18, 2012 | 6 | 0 | 0 | 6 | Read full report |
Deficiencies cited in this report: PATIENT RIGHTS: RESTRAINT OR SECLUSION AUTOPSIES NURSING SERVICES RN SUPERVISION OF NURSING CARE NURSING CARE PLAN SUPERVISION OF CONTRACT STAFF |
