• Facility failed to obtain a TB skin test on 4 staff members. This is a disregard for the health and safety of the staff as well as the patients
  • There was no documentation of training and in-service on 5 staff members
  • Narcotics were not stored safely to prevent access by unauthorized personnel
  • There was visible dried blood on the top of the sharps container, which was full, in a treatment room
  • There were syringes containing propofol (an anesthesia medication) in the regular trash in the hallway, accessible to patients.
  • Repeat violation: Facility failed to obtain a TB skin test on 4 staff members. This is a disregard for the health and safety of the staff as well as the patients
  • There were expired medications and supplies available for staff use on patients in the facility -some opened, in use and as old as 12 years. The LPN that was interviewed stated that she “wasn’t sure” if the facility conducted audits related to expired medications and supplies. An RN was interviewed and she stated that she “was unsure” if the facility conducted these audits as well. The executive director was interviewed and she stated the facility previously conducted monthly audits however there had not been “consistent staffing”.
  • The epinephrine on the anesthesia crash cart was expired. The nurse anesthetist was interviewed and stated that she used the cart to manage patients during their procedures and she checked the cart “everyday” but did not “realize” the medication was expired. The vial expired in January 2018 and this inspection was completed in October 2018.
  • Repeat violation: the facility failed to present a quality improvement program that monitored indicators of quality care. The executive director revealed that she was involved in the quality assurance program for the facility however it had not “been a priority”. She stated the previously cited violation for staff not having a TB skin test was not in their QA program, so the previous violation had not been corrected.
  • The owner/MD was interviewed and he stated that he was “not involved with audits, reviews or operation of the facility”. He stated that he was “unable to answer any nursing questions” and to direct those to the executive director of the facility, who is in an administrative not clinical position.
Report 2015 Report 2018
DISCLAIMER: All of the inspection reports on this site were acquired through public records request to state departments of health and public records online.