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Tag No.: K0321
Based on observations during the tour of the hospital, patient room 26 is being used as storage. The storage goes all the way to the entrance from the back of the room. This is not a rated room.
Based on observations during the tour of the hospital, the shower in patient room 10 is being used as storage. This is not a rated room, nor a storage room.
Based on observations during the tour of the hospital, the shower room off the patient corridor is being used as storage. This is not a rated room, nor a storage room.
Based on observations during the tour of the hospital, the soiled linen storage room door does not latch.
Tag No.: K0345
Based on observations during the tour of the hospital, a red tag was on the fire alarm panel. Provide a current Fire Marshall report which indicates the fire alarm system is satisfactory.
Tag No.: K0353
During the review of the facility's records, fire sprinkler inspection reports were missing from 3 quarterly inspections from 2020 and the annual quarterly inspection from 2021.
Tag No.: K0355
During the review of the facility's records, two Annual Fire Extinguisher inspection reports from 2020 and 2021 were missing.
Tag No.: K0521
Based on observations during the tour of the hospital, the patient toilet room for the lab department is not functioning.
Tag No.: K0741
Based on observations during the tour of the hospital, patients and staff were smoking in an area that may not have been designated as smokeing area. Please provide your non-smoking policy.
Tag No.: K0914
Based on review of the records, three generator weekly reports from March 2020 were missing.
Based on review of the records, three generator weekly reports from June 2020 were missing.
Based on review of the records, the the generator will not run for more than a few minutes at a time and since the installation of the new generator weekly and monthly testing has not been able to ever achieve 30% run on the generator. Provide weekly reports to this department showing testing of the generator and service provider's reports.