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Tag No.: K0111
Based on observation, record review and interviews by surveyors 16732 and 37695
The facility was under going renovation and did not get a plan review for the project. The facility had hired an architect for the project and plans were drawn up. The project included:
a) Making new closet space
b) Making new doctors dictation room
c) Changing and adding doors
d) Renovations to registration area
The facility director and CEO confirmed these findings
Tag No.: K0331
Based on observation of surveyor 37695 on 12/31/18
Non fire rated plastic was being used to enclose a barrier for a subject doing a painting project in the lobby of the hospital.
This was confirmed with the facility manager