Jewish Home & Rehab Center

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 48731 Based on record review and interview, the facility failed to maintain the fire alarm system. This was evidenced by the failure to conduct a semi-annual fire alarm inspections of the devices. This affected 11 of 11 patients in two of two smoke compartments. This could result in a malfunction of the fire alarm system. NFPA 101: Life Safety Code, 2012 Edition 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 72: National Fire Alarm and Signaling Code, 2010 Edition 14.1 Application. 14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter. 14.3.1 * Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction. 14.3.2 Devices or equipment that is inaccessible for safety considerations (e.g., continuous process operations, energized electrical equipment, radiation, and excessive height) shall be permitted to be inspected during scheduled shutdowns if approved by the authority having jurisdiction. 14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance. Table 14.3.1 Frequencies-Semiannually 9. Initiating devices 13. Alarm notification appliances 14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction. Table 14.4.5 Testing Frequencies 14.6.2 Maintenance, Inspection, and Testing Records. 14.6.2.1 Records shall be retained until the next test and for 1 year thereafter. 14.6.2.4 * A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4: (1) Date (2) Test frequency (3) Name of property (4) Address (5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number (6) Name, address, and representative of approving agency(ies) (7) Designation of the detector(s) tested (8) Functional test of detectors (9)* Functional test of required sequence of operations (10) Check of all smoke detectors Findings: During record review and interview with the Director of Facilities on 8/27/24, fire alarm system records were requested and reviewed. At 11:00 a.m., the facility failed to provide a semi-annual FAS inspections record upon request. The report titled, “Fire Alarm Inspection Report” dated 8/19 to 8/20 of 2024, listed under “1st Floor East Wing (K1E)” showed 2 manual pull stations (By Elevator, 2M123), 27 smoke detectors (Corr. by Elevator, Nurse Station Corridor, Nurse Station at Elev, Meds RM, two in Nurse Station, Conf RM, Shower RM, Group RM, In Activity RM, Fire Doors East, Fire Doors West, Corr by RM 635, Corr by RM 631, In Room 626, In Room 628, In Room 630, In Room 632, In Room 634, In Room 636, In Room 638, In Room 637, In Room 635, In Room 633, In Room 631, In Room 629, In Room 627), and 8 duct detectors (Two In Activity RM, Corr by RM 626, In Soiled Linen Closet RM 156, In Closet by RM 625, In Room 625, Nurse Station, Corr Entrance to Wing) were last tested on 8/19/24. Upon interview, the Director of Facilities stated that the vendor was likely inspecting using different codes.”

“Smoke Detection CFR(s): NFPA 101 Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2 This Standard is not met as evidenced by: 48731 Based on record review and interview, the facility failed to maintain the smoke detectors. This was evidenced by the failure to provide a smoke detector sensitivity test. This affected 11 of 11 patients and two of two smoke compartments. This could result in a delay of notification in the event of smoke and fire. NFPA 101, Life Safety Code, 2012 Edition 19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6 9.6 Fire Detection, Alarm, and Communications Systems. 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition 10.15* Protection of Fire Alarm System. In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s), notification appliance circuit power extenders, and supervising station transmitting equipment to provide notification of fire at that location. Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted. 14.4.5.3.1 Sensitivity shall be checked within 1 year after installation. 14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3 14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. 14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained. 14.4.5.3.3.2 In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods: (1) Calibrated test method (2) Manufacturer ’ s calibrated sensitivity test instrument (3) Listed control equipment arranged for the purpose (4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range (5) Other calibrated sensitivity test methods approved by the authority having jurisdiction 14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6, smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced. 14.4.5.3.6 Smoke detectors or smoke alarms listed as field adjustable shall be permitted to either be adjusted within the listed and marked sensitivity range, cleaned, and recalibrated, or be replaced. 14.4.5.3.7 The detector or smoke alarm sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector or smoke alarm. Findings: During record review and interview with the Director of Facilities on 8/27/24, the smoke detector sensitivity test records were requested. At 2:41 p.m., the facility failed to provide records that a smoke detector sensitivity test was conducted. No prior sensitivity records for the unit were provided for review. Upon interview, the Director of Facilities stated that the missing sensitivity was likely due to a vendor error.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 48731 Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system. This was evidenced by the failure to maintain the sprinkler system components. This affected 11 of 11 patients in one of two smoke compartments. This could result in the failure of the sprinkler system to operate. NFPA 101, Life Safety Code, 2012 Edition 19.3.5 Extinguishment Requirements. 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7 unless otherwise permitted by 19.3.5.5. 9.7 Automatic Sprinklers and Other Extinguishing Equipment. 9.7.1 Automatic Sprinklers. 9.7.1.1 * Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition. 5.2.1 Sprinklers. 5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall). Findings: During a tour of the facility and interview with the Director of Facilities on 8/26/24, the sprinkler heads were observed. At 4:30 p.m., one of two sprinkler heads in Resident Room 627 was covered by an accumulation of foreign material. Upon interview, the Director of Facilities stated that the sprinkler head was likely overlooked.”

“Electrical Systems - Maintenance and Testing CFR(s): NFPA 101 Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99) This Standard is not met as evidenced by: 48731 Based on record review and interview, the facility failed to maintain the receptacles at patient bed locations. This was evidenced by no receptacles test records. This affected 11 of 11 patients and one of two smoke compartments. This could result in a delay in notification of a malfunctioning receptacle. Findings: During record review and interview with the Director of Facilities on 8/27/24, the receptacle testing records were requested and reviewed. At 2:00 p.m., the facility failed to provide documentation indicating the hospital grade receptacles at patient bed locations were tested after the initial installation, replacement, or servicing of the devices. There were no prior receptacle test and interval defined by documented performance data provided for review. Upon interview, the Director of Facilities stated that the receptacles had not been cited on previous surveys.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 48731 Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by a power strip plugged into a power strip. This affected one of two smoke compartments in the Nurse Station’s Conference room. This could result in the increased risk of an electrical fire. Findings: During a tour of the facility and interview with the Director of Facilities on 8/26/24, the electrical equipment was observed. At 4:40 p.m., a white power strip was plugged into another white power strip in the Conference Room of the Nursing Station. The first power strip was powering the second power strip and a laptop charger. The second power strip was powering two walkies-talkies and a phone charger. Upon interview, the Director of Facilities stated that a vendor likely set up the electrical equipment.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 26917 Based on observation, interview, and document review the hospital failed consistently adhere to its established policy for the safe administration of eyedrops. The investigation revealed proper compression techniques were not applied to minimize systemic absorption. This inconsistency demonstrates a failure to maintain the standards outlined in the hospital’s medication safety protocols, potentially compromising patient safety and the effectiveness of the administered treatments. Findings: A review conducted on 08/21/24, of the hospital policy titled “Specific Medication Administration Procedures - Eyedrop Administration, Section 8.5,” dated June 2015, highlighted the following guidelines for administering eyedrops: When applying the eyedrops, ensure that the patient’s eye is closed. To reduce the systemic absorption of the medication, gently compress the tear duct, located at the inner corner or inner canthus of the eye, using one finger for one to two minutes. As an alternative method, the resident may be instructed to keep their eyes closed for approximately three minutes. These procedures are designed to optimize the administration of eyedrops and minimize potential side effects. Healthcare professionals should adhere to these guidelines to ensure safe and effective medication delivery. During an observation in the Acute Psychiatric Hospital on 08/21/24, at 10:30 AM, LVN 1 administered Brimonidine 0.2% and Levobunolol 0.5% eye drops to Patient 1. However, after instilling the drops, the nurse did not use one finger to compress the tear duct, also known as the inner corner or inner canthus of the eye, for one to two minutes, which is recommended to reduce the systemic absorption of the medication. Additionally, the resident was not instructed to keep their eyes closed for approximately three minutes as an alternative method to minimize absorption. To ensure optimal administration of eye drops and reduce potential side effects, it is essential for healthcare professionals to follow proper techniques, such as gentle compression of the tear duct or instructing patients to keep their eyes closed for a recommended duration. During an interview conducted on 08/21/24, at 10:45 AM, LVN 1 admitted that she had inadvertently forgotten to apply pressure with her finger to the tear duct while administering eye drops. LVN 1 expressed her intention to improve her technique and remain more vigilant in the future, acknowledging her oversight. This demonstrates her willingness to learn from the incident and ensure that proper medication administration protocols are followed for optimal patient care and safety.”

“PHARMACIST SUPERVISION OF SERVICES CFR(s): 482.25(b)(1) §482.25(b)(1) - All compounding, packaging, and dispensing of drugs and biologicals must be under the supervision of a pharmacist and performed consistent with State and Federal laws. This Standard is not met as evidenced by: 26917 Based on interviews and document reviews, it was determined that the hospital did not fulfill its obligation to conduct monthly unit inspections on all nursing stations. Evidence revealed that only one nursing station in each tower received a pharmacist inspection each month, leaving most nursing stations without a routine pharmacist inspection. This failure to consistently assess medication management practices across all nursing stations may pose potential risks to patient safety and raises concerns about the hospital’s adherence to established guidelines and regulations. Findings: A review of the hospital policy dated December 2017, titled “Organizational Aspects - Consultant Pharmacist Services Provider Requirements, Section 1.2,” the responsibilities of the consultant pharmacist encompass various activities. These duties include, but are not limited to, the monthly inspection of medication storage areas for proper storage, labeling of medications, cleanliness, and the removal of expired medications. This policy underscores the importance of regular assessments to ensure appropriate management of medications within the hospital setting. During an interview on 8/21/24, at 2:00 PM, Registered Pharmacist 1 explained that they conduct unit inspections on one nursing station of each tower every month, with three towers in total. Since each tower consists of multiple floors, Registered Pharmacist 1 clarified that the nursing stations in each area of the hospital are not inspected monthly. Rather, only one nursing station from each of the three towers, each tower had between two to four floors each with one nursing station on each floor, undergoes inspection by the pharmacist every month. Not all nursing units were inspected monthly. A review on 08/21/24 of the monthly unit inspections revealed that only one nursing station, was inspected in each tower. This indicates that most of the nursing stations across the hospital did not receive a pharmacist unit inspection monthly, raising concerns about the consistency and thoroughness of these inspections in ensuring proper medication management and patient safety throughout the facility. During an interview on 8/22/24, at 10:00 AM, Registered Pharmacist 1 provided an overview of the hospital’s three towers: the Goodman tower, the Koret tower, and the Friedman tower. Registered Pharmacist 1 explained that the Goodman tower has four floors with four nursing stations, the Koret tower has two floors, and the Friedman tower has three floors. Each of these floors houses one nursing station. Registered Pharmacist 1 confirmed that unit inspections are conducted monthly, with one nursing station from each building being inspected per month. Most of the nursing stations did not have a monthly unit inspection. According to her knowledge, this inspection frequency has remained consistent throughout her one-year tenure at the hospital.”