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The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See C-231

The facility failed to provide a safe environment by not properly storing oxygen cylinders.

Findings Include:

During the facility tour on 7/14/2010 with the Maintenance Technician is was observed that two oxygen cylinders were not securely stored to prevent tipping over. The oxygen cylinders were located in a storage closest on the acute care wing.

The facility failed to provide a clean environment by storing items in the sink base cabinet. Findings Include:

During the facility tour conducted on 7/14/2010 with the X-Ray Nurse at the Mackinac Island Campus it was observed that items were being stored under the sinks. Storage under the sink was observed in X-Ray, Laboratory, and Exam Rooms 1 thru 4. Items stored included paper towels, stuffed animals, gloves, and misc. patient care items.

During the facility tour conducted on 7/14/2010 with the Maintenance Tech at the Main Hospital Campus storage under the sink was observed in Med Room and the Laboratory. Items stored included paper towels, syringes, vases, and small lab equipment.

The facility failed to provide adequate lighting in the patient care area. Findings Include:

During the facility tour on 7/14/2010 with the Maintenance Tech the lighting level at the handwash sink serving the blood draw rooms measured 16 foot candles. This is below the minimum 30 foot-candles of illumination required per the Illuminating Engineering Society of North America, IESNA Publication CP29, Lighting for Health Facilities.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on July 7, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated July 7, 2010 for Life Safety Code.