Jewish Healthcare Center

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included to administer an anti-anxiety medication three times per day, the facility failed to ensure professional standards of practice were maintained when nursing changed the order for the medication to be administered only twice a day, without consulting a physician, in accordance with nursing best practice and facility policy.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure they maintained a complete and accurate medical record related to meal percentage intakes for five out of 14 applicable meals.

Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure that one Resident (#110) out of a total sample of 26 residents was provided the right to participate in the care plan process. Specifically, the facility failed to ensure that Resident #110 was provided the opportunity to participate in his/her initial and quarterly care plan meetings and also failed to document in the medical record why the Resident could not or did not participate in the two care plan meetings.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice relative to the care and maintenance of oxygen equipment for one Resident (#84) out of a total sample of 26 residents. Specifically, for Resident #84, the facility failed to ensure that an oxygen concentrator filter was maintained in a clean and sanitary manner. Resident #84 was admitted to the facility in October 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #84 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of a total possible score of 15. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the medication error rate was not five percent (5%) or greater when one Nurse (#1) out of three Nurses observed during the medication pass procedure, made two errors in 26 total opportunities, for a medication error rate of 7.69%, impacting one Resident (#119) of six residents observed, out of a total sample of 26 residents. Specifically, for Resident #119, the facility failed to: ensure that Nurse #1 followed the Physician orders for Losartan Potassium (blood pressure medication used to treat hypertension) to be held when Resident #119's systolic blood pressure (the top/upper number for blood pressure measurement) reading was less than 130 mmHg (millimeters of mercury). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that medication was stored in a safe and sanitary manner in the medication carts on one (Fifth-Floor North) out of four medication carts reviewed. Specifically, the facility failed to ensure that Nurse #2 stored medications in a safe and sanitary manner in the Fifth-Floor North medication cart when Nurse #2 was observed storing one pre-poured medication cup containing resident medications in the top drawer and a second medication cup containing pre-poured resident medications in the bottom drawer of the medication cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for food safety relative to the use and preparation of unpasteurized eggs to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility staff failed to utilize pasteurized eggs for the preparation of over easy (eggs fried on both sides with a runny yolk) eggs to safely accommodate resident's choices during the breakfast meals and ensure that the unpasteurized eggs being used were appropriately cooked until all parts of the egg were completely firm placing the residents who were served the over easy, unpasteurized eggs at risk for foodborne illness.

Inspectors wroteBased on record and policy review, and interview, the facility failed to ensure a Preadmission Screening and Resident Review Level I (PASRR-screening that assesses for Serious Mental Illness or Developmental Disabilities [Level I screen (initial pre-screening completed prior to admission to a Nursing Facility]) was completed prior to admission for one Resident (#107) out of a total sample of 26 residents. Specifically, for Resident #107, the facility failed to ensure that a Level I screen was completed prior to the Resident's admission to the facility to assist in determining the level of services needed.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections within the facility on one Unit (Fourth Floor) out of three total Units. Specifically, the facility failed to: 1) clean and disinfect a glucometer (device used to test sugar level in the blood) after resident use to prevent potential contamination and potential transmission of blood-borne disease. 2) ensure wound care supplies brought into a resident room were designated for use on that resident and stored in that resident's room to prevent potential cross-contamination.

Inspectors wroteBased on record review, interviews, and observations, the facility failed to assess, manage, and effectively treat one Resident (#394) out of a total sample of 26 residents for pain. Specifically, the facility staff failed to assess Resident #394 in a timely manner for pain, provide pain medication as needed upon the Resident's request, and re-assess for the effectiveness of the Resident's pain medication, which prevented the Resident from participating in his/her scheduled Physical Therapy session.

Inspectors wroteBased on observations, policy review, and interviews, the facility failed to provide a dignified dining experience for one Resident (#14) out of a total sample of 26 residents. Specifically, staff stood over the Resident while feeding meals, rather than sitting at eye level.

Inspectors wroteBased on interview and record review, the facility failed to refer two Residents (#81 and #110) out of three applicable residents, in a total sample of 26 residents for a Level II evaluation (an in-depth evaluation of a person who has a positive Level I screen for Mental Illness (MI), intellectual disability, or related condition in order to determine if they require specialized services) Preadmission Screening and Resident Review (PASRR). Specifically, the facility staff failed to refer both Residents for a Level II evaluation for: 1. Resident #81 who was identified post admission to have a diagnosis of MI and had limitations in major life activities due to MI within the last six months of his/her admission to the facility. 2. Resident #110 who required an inpatient Psychiatric hospitalization.

Inspectors wroteBased on record review and interview, the facility failed to develop a baseline care plan for one Resident (#423) out of a total sample of 26 residents. Specifically, facility staff failed to develop a baseline care plan for Resident #423 as required, and did not develop a comprehensive care plan in its place within 48 hours of the Resident's admission to the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an indwelling Foley/urinary catheter (a tube placed through the urethra into the bladder to drain urine) care, per professional standards of practice for one Resident (#380) out of a total sample of 26 residents. Specifically, the facility staff failed to obtain Physician's orders and develop a plan of care for the care and management of Resident #380's Foley catheter.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide care according to professional standards of practice for one Resident (#59) with a Gastrostomy tube (G-tube - also known as a feeding tube: medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake) out of three applicable sampled residents, in a total sample of 26 residents. Specifically, facility staff failed to administer enteral (delivery of nutrients through a feeding tube directly into the stomach) feedings according to the Physician orders, monitor and accurately record the amount of enteral feed administered to Resident #59, when the Resident was not allowed to take any nutrition by mouth (NPO), which increased the Resident's risk for reduced nutritional intake.

Inspectors wroteBased on observation, record review, and interview, the facility failed to store all drugs in locked compartments, as required, for one Resident (#59) out of a total sample of 26 residents. Specifically, for Resident #59, the facility staff failed to store all drugs in a locked compartment when medications were observed stored in the Resident's room, not locked, and accessible to unauthorized persons.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to store food in accordance with professional standards for food service safety for two of nine applicable unit refrigerators. Specifically, the unit refrigerators on the 3 North Unit and the 3 East Unit contained expired and unlabeled food items.