Beth Israel at Shalom Park

In the surveyor’s words

From the most serious findings on record at Beth Israel at Shalom Park, in the surveyor’s own words.

• Actual harm, isolatedF760Sep 9, 2021

  Based on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#1) out of three sample residents. Specifically, the facility failed to ensure a registered nurse (RN) #1 administered the pain medication, [MEDICATION(S)], to Resident #1 according to the physician order. RN #1 administered [MEDICATION(S)] to the resident at four times the ordered dose in error due to misinterpreting the order. Resident #1 passed away an hour and a half after the administration of the [MEDICATION(S)]. Resident #1 was a hospice patient, actively dying at the time of the medication error, the error caused a medication overdose which hastened his death. […]

• No harm, potential for more than minimal, widespreadF812Jul 13, 2022

  Based on observations, interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety. Observations in the kitchen/dry storage area revealed food items in the refrigerators, freezers, and dry storage were not dated nor labeled with an expiration date. This failed practice had the potential to affect 121 residents who received food from the main kitchen. Findings included: A review of the facility policy titled, Food and Supply Storage, revised ,d+[DATE], revealed, Policies: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. […]

• No harm, potential for more than minimal, patternF759Jul 13, 2022

  Based on observations, interviews, record review, and facility policy review, the facility failed to maintain a medication error rate of 5% or less. There were two errors out of 31 opportunities for error, which resulted in a 6.45% medication error rate for 1 (Resident #73) of 4 residents observed during medication pass. Findings included: A review of the facility policy titled, Medication Administration, dated 11/20/2020, revealed, Policy Explanation and Compliance Guidelines: 10. Review MAR [Medication Administration Record] to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc. [et cetera]) with MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy also indicated, 14. […]

• No harm, potential for more than minimal, patternF761Apr 29, 2021

  Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards in one of three medication rooms, and two of six medication carts. Specifically, the facility failed to: -Date two vials of [MEDICATION(S)] when opened on the first skilled floor; -Date a Wixela inhaler when opened on the third floor west medication cart; and, -Date a Breo inhaler when opened on the third floor east medication cart. I. […]

• No harm, potential for more than minimal, patternF812Apr 29, 2021

  Based on observation, record review and interviews the facility failed to ensure food safety and sanitation of personal resident refrigerators on three of three floors. Specifically, the facility failed to ensure personal resident refrigerators were maintained, monitored, and cleaned. Findings include: I. Facility policy and procedure The Resident Room Refrigerator policy, updated [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 2:32 p.m. It read in pertinent part, Refrigerators and freezers will be cleaned, (and) contents properly stored. Housekeeping will check refrigerators to verify appropriate storage and cleanliness as part of routine cleaning of resident rooms. […]