Inspection Report
Follow-Up
Deficiencies: 0
Feb 28, 2025
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited tags have been corrected as noted during the follow-up survey.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 28, 2025
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 5, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for the William Breman Jewish Home, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Feb 5, 2025
Visit Reason
A revisit was conducted to verify correction of deficiencies cited as a result of the recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected as of 1/24/2025.
Inspection Report
Abbreviated Survey
Census: 91
Deficiencies: 0
Jan 29, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted at William Breman Jewish Home investigating two complaint intake numbers GA00253601 and GA00263560 on January 29, 2025.
Findings
Complaint Intake Number GA00253601 was found unsubstantiated with no deficiency cited. Complaint Intake Number GA00253560 was substantiated with no deficiency cited.
Complaint Details
Complaint Intake Number GA00253601 was unsubstantiated with no deficiency cited. Complaint Intake Number GA00253560 was substantiated with no deficiency cited.
Inspection Report
Life Safety
Census: 83
Capacity: 96
Deficiencies: 2
Jan 2, 2025
Visit Reason
A Life Safety Code Federal Monitoring Survey was conducted following a state agency survey to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.
Findings
The facility was found not in substantial compliance with life safety code requirements, including failure of elevator lobby doors to self-close and inadequate monthly diesel generator exercises and missing annual diesel fuel testing documentation.
Severity Breakdown
E: 1
F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Doors in an exit passageway, stairway enclosure, or hazardous area enclosure failed to self-close due to door wedges on the 4th and 5th floor elevator lobby doors. | E |
| The facility failed to exercise the diesel generator monthly for the required 30 minutes and lacked documentation of the required annual diesel fuel quality test in 2024. | F |
Report Facts
Census: 83
Total Capacity: 96
Deficiency count: 2
Generator exercise duration: 5
Inspection Report
Life Safety
Census: 90
Capacity: 95
Deficiencies: 3
Dec 12, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to conduct an annual fire alarm inspection, missing documentation for 2nd and 3rd quarter fire drills, and failure to perform monthly 30-minute generator load tests. These deficiencies could affect the safety of 95 residents.
Severity Breakdown
F: 2
D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| No annual fire alarm inspection conducted within the 12 month period; no report documented. | F |
| Missing documentation for 2024 2nd and 3rd quarter fire drills. | D |
| Failure to conduct monthly generator load tests for 30 minutes; no documentation and staff unaware of requirement. | F |
Report Facts
Residents affected: 95
Certified Beds: 95
Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff interviewed and confirmed findings related to fire alarm inspection, fire drills, and generator load tests |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 2
Dec 12, 2024
Visit Reason
A State Licensure survey was conducted from December 10, 2024 through December 12, 2024 to assess compliance with state health regulations at The William Breman Jewish Home.
Findings
The inspection revealed deficiencies including a medication error rate of 10% due to incorrect medication administration by nursing staff, and failures in food labeling, dating, storage, and sanitation in the kitchen, including an unclean ice machine and expired dry storage items.
Deficiencies (2)
| Description |
|---|
| Medication error rate exceeded five percent with three errors out of 30 opportunities by nursing staff during medication administration. |
| Improper food labeling, dating, and storage in the reach-in cooler; failure to discard expired dry storage food items; and unsanitary conditions of the ice machine. |
Report Facts
Medication errors: 3
Medication opportunities: 30
Facility census: 85
Expired dry storage items: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Involved in medication errors during administration to Resident R50. |
| LPN DD | Licensed Practical Nurse | Involved in medication error during administration to Resident R19. |
| Dietary Supervisor HH | Dietary Supervisor/Cook | Confirmed labeling and dating responsibilities and cleaning of ice machine. |
| Facility Tech II | Responsible for cleaning the ice machine and described cleaning procedures. | |
| DM | Chef/Dietary Manager | Conducted kitchen tour and confirmed food labeling/dating and cleaning responsibilities. |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 3
Dec 12, 2024
Visit Reason
A recertification survey was conducted from December 10 through December 12, 2024, including investigation of two complaint intake numbers which were unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to advanced directives documentation, medication administration errors, and food storage and sanitation issues.
Complaint Details
Complaint Intake Numbers GA00250619 and GA00251026 were investigated and found unsubstantiated.
Severity Breakdown
D: 2
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility did not properly maintain record of and correct orders for one resident's advanced directive choice, risking residents' wishes not being honored in emergencies. | D |
| Facility failed to ensure medication error rate was less than 5%, with three medication errors out of 30 opportunities (10% error rate) involving two nurses. | D |
| Facility failed to ensure proper food labeling, dating, and storage, failed to discard expired dry storage food items, and failed to maintain sanitary condition of the ice machine. | F |
Report Facts
Medication errors: 3
Medication opportunities: 30
Residents: 85
Sampled residents: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Registered Nurse | Acknowledged responsibility for failing to update code status from CPR to DNR. |
| BB | Licensed Practical Nurse | Involved in medication errors during administration. |
| DD | Licensed Practical Nurse | Involved in medication errors during administration. |
| HH | Dietary Supervisor/Cook | Confirmed responsibility for food labeling and cleaning procedures. |
| Facility Tech II | Responsible for cleaning the ice machine; admitted possible incomplete cleaning. | |
| DM | Chef/Dietary Manager | Confirmed daily checks for food labeling and expiration. |
| Director of Nursing | Director of Nursing | Confirmed expectations for accurate advanced directive orders and medication administration. |
| Administrator | Administrator | Emphasized protocol for obtaining and entering POLST forms and ensuring patient wishes are honored. |
Inspection Report
Abbreviated Survey
Census: 92
Deficiencies: 0
Aug 27, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints numbered GA00249257, GA00249512, GA00248878, GA00244043, and GA00249479.
Findings
All complaints investigated during the survey were unsubstantiated with no regulatory violations cited.
Complaint Details
Complaints GA00249257, GA00249512, GA00248878, GA00244043, and GA00249479 were investigated and found to be unsubstantiated with no regulatory violations.
Report Facts
Complaint numbers investigated: 5
Inspection Report
Abbreviated Survey
Census: 87
Deficiencies: 0
Nov 22, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaint #GA00238598.
Findings
The complaint #GA00238598 was unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Complaint Details
Complaint #GA00238598 was investigated and found to be unsubstantiated.
Report Facts
Total census: 87
Inspection Report
Deficiencies: 0
Oct 4, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for the William Breman Jewish Home, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Oct 4, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 7/31/22 recertification/complaint survey.
Findings
All deficiencies cited in the previous 7/31/22 survey were found to be corrected during the revisit survey.
Report Facts
Census: 87
Inspection Report
Follow-Up
Deficiencies: 0
Sep 21, 2022
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Deficiencies: 1
Aug 16, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 08/08/2022 and 08/14/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period. | F |
Report Facts
Reporting period: 7
Inspection Report
Life Safety
Census: 85
Capacity: 95
Deficiencies: 2
Aug 3, 2022
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system maintenance.
Findings
The facility was found not in substantial compliance due to deficiencies in the sprinkler system, including a yellow tag indicating unresolved issues and lack of documentation for the five-year internal sprinkler system test, potentially placing 95 residents and staff at risk.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain sprinkler system riser; yellow tag dated 7/20/2022 with no report on site documenting deficiencies. | SS=F |
| No documentation of the five-year internal test of the sprinkler system on site. | SS=F |
Report Facts
Census: 85
Total licensed beds: 95
Date of yellow tag: Jul 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour on 8/3/2022 |
Inspection Report
Renewal
Deficiencies: 6
Jul 31, 2022
Visit Reason
The inspection was a Licensure Survey conducted from July 29, 2022 through July 31, 2022 to assess compliance with licensure requirements.
Findings
The facility was found deficient in implementing a person-centered comprehensive care plan for pain management for one resident, failing to evaluate the effectiveness of prescribed pain medications. Additionally, the facility failed to maintain sanitary conditions in the kitchen, including improper stacking of wet cookware, unlabeled and undated food items, failure to discard leftover food by discard date, unsanitary conditions of kitchen appliances, and improper use of the three-compartment sink.
Deficiencies (6)
| Description |
|---|
| Failed to implement the person-centered comprehensive care plan for pain management for one resident and failed to evaluate effectiveness of prescribed pain medications. |
| Failed to maintain sanitary conditions of cookware by stacking wet cookware (wet nesting) to prevent bacterial growth. |
| Failed to ensure food items were labeled and dated. |
| Failed to discard leftover food by discard date. |
| Failed to maintain sanitary conditions of the stand-up mixer to prevent cross contamination. |
| Failed to properly use the 3-compartment sink correctly to prevent food borne illness. |
Report Facts
Residents potentially affected: 81
Sampled residents: 24
Resident ID: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in pain management deficiency related to resident #63. |
| LPN CC | Licensed Practical Nurse | Confirmed resident #63 was yelling and gave PRN pain medication. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding pain management for resident #63. |
| Director of Dining Services | Director of Dining Services (DDS) | Interviewed regarding kitchen sanitation deficiencies. |
| Dietary Aide AA | Dietary Aide | Observed washing dishes improperly in three-compartment sink. |
Inspection Report
Routine
Census: 84
Deficiencies: 4
Jul 31, 2022
Visit Reason
A standard survey was conducted from 7/29/22 through 7/31/22, including investigation of two complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to implement a comprehensive person-centered care plan related to pain management for one resident, failure to evaluate effectiveness of prescribed pain medications, failure to ensure gradual dose reduction of psychotropic medications, and multiple food safety and sanitation violations in the kitchen.
Complaint Details
Complaint Intake Numbers GA00226004 and GA00216481 were investigated in conjunction with the standard survey.
Severity Breakdown
SS= D: 3
SS= F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to implement the person-centered comprehensive care plan for one resident related to pain management. | SS= D |
| Failed to evaluate the effectiveness of prescribed pain medications for one resident. | SS= D |
| Failed to ensure gradual dose reduction of psychotropic medications for one resident. | SS= D |
| Failed to maintain sanitary conditions in food procurement, storage, preparation, and service including wet nesting of cookware, unlabeled and undated food items, leftover food not discarded by discard date, unclean kitchen equipment, and improper use of the three-compartment sink. | SS= F |
Report Facts
Resident census: 84
Medication dose: 2.5
Medication dose: 5
Medication dose: 0.25
Medication dose: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in findings related to failure to administer pain medication timely for resident #63. |
| LPN CC | Licensed Practical Nurse | Named in findings related to administration of PRN morphine sulfate for resident #63. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding pain management and medication administration for resident #63 and medication review process. |
| Director of Dining Services | Director of Dining Services (DDS) | Interviewed regarding food safety and sanitation deficiencies in the kitchen. |
| Dietary Aide AA | Dietary Aide | Observed washing dishes improperly in the three-compartment sink. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 18, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00211791, #GA00211017, and #GA00206685.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaints #GA00211791, #GA00211017, and #GA00206685 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Routine
Census: 66
Deficiencies: 0
Oct 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Routine
Census: 76
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and 42 CFR §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 7, 2020
Visit Reason
An abbreviated survey was conducted to investigate complaint number GA00201073.
Findings
The complaint was substantiated but no regulatory deficiencies were cited.
Complaint Details
Complaint number GA00201073 was substantiated with no regulatory deficiencies cited.
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 0
May 8, 2019
Visit Reason
A revisit survey was conducted on 5/7-8/2019 to verify correction of deficiencies cited during the 2/28/2019 recertification survey.
Findings
All deficiencies cited as a result of the 2/28/2019 recertification survey were found to be corrected.
Inspection Report
Life Safety
Census: 94
Capacity: 96
Deficiencies: 0
Feb 28, 2019
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety regulations and related standards for participation in Medicare/Medicaid.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the related National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition standards.
Report Facts
Stories: 4
Construction Type: 1
Certified Beds: 96
Census: 94
Inspection Report
Routine
Census: 94
Deficiencies: 4
Feb 28, 2019
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations for a long-term care facility. The visit included review of resident care, advance directives, restraint use, and transfer procedures.
Findings
The facility was found not in substantial compliance with regulations, with actual harm identified due to improper transfer of a resident resulting in a fracture. Deficiencies included failure to accurately document advance directives, improper use of restraints without physician orders, failure to follow care plan for transfers requiring two staff, and inadequate supervision leading to resident injury.
Severity Breakdown
Level D: 2
Level G: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to accurately document Advance Directive status for Resident #18, including conflicting code status and use of an unsigned POLST form. | Level D |
| Failure to ensure Resident #296 was free from physical restraints; seatbelt used without physician order or assessment. | Level D |
| Failure to follow care plan requiring two-person assistance for transfers for Resident #67, resulting in improper transfer and injury. | Level G |
| Failure to ensure a safe environment and adequate supervision to prevent accidents, resulting in Resident #67 sustaining a left arm fracture during transfer by one staff member. | Level G |
Report Facts
Resident census: 94
Sample size for Advance Directive review: 17
Residents reviewed for restraints: 39
Residents reviewed for transfers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA EE | Certified Nursing Assistant | Involved in improper transfer of Resident #67 resulting in fracture; did not follow care plan or check Kardex. |
| MDS Coordinator A | Provided care plan and MDS information regarding Resident #18's advance directives. | |
| Director of Nursing (DON) | Director of Nursing | Confirmed deficiencies related to advance directives and restraint use; provided follow-up documentation. |
| Social Worker (SW) | Social Worker | Described process for obtaining advance directives and acknowledged documentation issues. |
| Registered Nurse FF | Registered Nurse | Explained use of seatbelt restraint for Resident #296 due to seizure risk. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Confirmed care plan requirements for Resident #67 transfers and described incident investigation. |
| Registered Nurse Supervisor DD | Registered Nurse Supervisor | Assessed Resident #67 after injury and interviewed CNA involved in transfer. |
| Director of Staff Development | Director of Staff Development | Reported lack of documentation for CNA EE in-service training on Kardex use. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 28, 2019
Visit Reason
The inspection was conducted to investigate complaints related to nursing care and the use of restraints at William Breman Jewish Home.
Findings
The investigation found that a resident (R#67) was transferred without following the care plan requiring two-person assistance, and a Certified Nursing Assistant failed to consult the resident's Kardex prior to transfer. Additionally, another resident (R#296) was observed with a seatbelt restraint without a physician's order or proper assessment, indicating improper use of restraints.
Complaint Details
The complaint investigation revealed substantiated issues regarding improper transfer techniques for resident R#67 and unauthorized use of restraints on resident R#296 without physician orders or assessments.
Deficiencies (2)
| Description |
|---|
| Failure to provide nursing care according to the patient's care plan, specifically transferring resident R#67 without the required two-person assistance. |
| Use of restraint (seatbelt) on resident R#296 without a physician's order or documented assessment. |
Report Facts
Date of survey completion: Feb 28, 2019
Date of incident interview: Feb 27, 2019
BIMS score: 10
BIMS score: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Interviewed regarding transfer incident with resident R#67; did not follow care plan or consult Kardex | |
| Assistant Director of Nursing (ADON) | Interviewed regarding resident R#67's transfer requirements and care plan | |
| Director of Nursing | Interviewed regarding improper use of restraint on resident R#296 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 16, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00187859 to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
Complaint #GA00187859 was investigated and no deficiencies were found.
Inspection Report
Re-Inspection
Census: 94
Deficiencies: 0
Apr 6, 2018
Visit Reason
A revisit survey was conducted to verify correction of previously cited deficiencies and to investigate Complaint Intake# GA00186704.
Findings
All previously cited deficiencies had been corrected, and the complaint investigation was found to be unsubstantiated.
Complaint Details
Complaint Intake# GA00186704 was investigated and found to be unsubstantiated.
Report Facts
Resident Census: 94
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 6, 2018
Visit Reason
A complaint survey was conducted on 4/6/18 investigating Intake# GA00186704.
Findings
The complaint was investigated and found to be unsustantiated.
Complaint Details
Complaint investigation for Intake# GA00186704 was conducted and found unsustantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 30, 2018
Visit Reason
A follow-up survey was conducted to verify that all previously cited deficiencies had been corrected.
Findings
The follow-up survey noted that all previously cited tags had been corrected.
Inspection Report
Life Safety
Census: 94
Capacity: 96
Deficiencies: 2
Feb 5, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and the National Fire Protection Association (NFPA) Life Safety Code 2012 Edition.
Findings
The facility was found not in substantial compliance due to failure to conduct sensitivity testing on smoke detectors within the last two years and failure to maintain accurate fire drill documentation for the 2nd and 3rd shifts during the 2017 calendar year.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to have sensitivity testing conducted on smoke detectors within the last 2 years; no documentation found on testing within the annual fire alarm inspection report. | SS= D |
| Failure to maintain accurate fire drill documentation for the 2nd and 3rd shifts during the 2017 calendar year. | SS= D |
Report Facts
Census: 94
Total Capacity: 96
Stories: 6
Construction Date: 1998
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during the tour and record review |
Inspection Report
Follow-Up
Deficiencies: 0
May 23, 2017
Visit Reason
A follow-up survey was conducted on 5/23/17 to the recertification survey to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior recertification survey were corrected at the time of this follow-up survey.
Inspection Report
Follow-Up
Deficiencies: 0
May 22, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected at the time of the follow-up survey.
Inspection Report
Life Safety
Census: 93
Capacity: 96
Deficiencies: 4
Mar 28, 2017
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including deficiencies in sprinkler system maintenance and testing, smoke barrier construction, electrical hazards, and oxygen gas storage safety. Multiple violations were observed during a tour with staff, placing residents and staff at risk in the event of fire.
Severity Breakdown
F: 1
D: 2
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Sprinkler system found with yellow tag status, missing sprinkler wrenches, no data plate, loaded and painted sprinkler heads, outdated 5-year inspection, and overdue fire pump annual inspection. | F |
| Smoke barrier construction compromised by electrical conduit penetrating fire barrier on the 3rd floor above a rated door. | D |
| Unsafe electrical conditions including use of multi-plug outlet strip on the floor in the Nurses Supervisors office. | D |
| Combustible storage placed too close to oxygen tanks in gas storage room, failing to provide protective clearances. | E |
Report Facts
Certified beds: 96
Census: 93
Fire Pump Annual Inspection overdue: 2015
5-year ITM inspection last done: 2011
Residents at risk due to smoke barrier deficiency: 24
Residents at risk due to electrical hazard: 24
Residents at risk due to oxygen storage hazard: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who accompanied the surveyor during the facility tour and confirmed findings |
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