Beth Israel at Shalom Park

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure electrical receptacles or cover plates have distinctive color or marking.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Emergency Preparedness Deficiencies

Establish procedures for tracking staff and patients during an emergency.

Emergency Preparedness Deficiencies

Establish policies and procedures for volunteers.

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This deficient practice could affect all residents, staff and visitors throughout the facility if an exit discharge to the public way is not provided. This was evidenced by the following: Egress doors located throug.. STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. This deficient practice could affect all residents, staff and visitors throughout the facility if an exit discharge to the public way is not provided. This was evidenced by the following: Egress doors located throug.. STANDARD is not met as evidenced by: Based review of the records and discussion during the survey, it was determined the facility failed to inspect and test the fire alarm system per NFPA 101, Chapter 9 (Section 9.6 Paragraph 9.6.1.4) and NFPA 72, (Chapter 7, Paragraph 7-1.2.2). Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff and visitor in the build if the fire alarm system failed to operate if a fire w.. STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8 This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. This was evid.. STANDARD not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-c.. STANDARD not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-c.. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on November17, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a three (3) story, Type II (111) construction. This original facility was constructed in 1992 and has a partial basement that is used for support servic.. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on November17, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a three (3) story, Type II (111) construction. This original facility was constructed in 1992 and has a partial basement that is used for support servic..