Jewish Home and Care Center

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that the kitchen remained free from live roach activity on the floor in the area of the sink and rodent droppings on the floor of the dry storage area. This had the potential to affect a census 75 residents that consume meals prepared in the kitchen.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for three of five residents reviewed for abuse out of a sample of 15 residents. The facility failed to report a resident-to-resident abuse incident between R3 and R4 and a staff-to-resident verbal abuse incident between Certified Nursing Assistant (CNA) 9 and R9. This failure could leave vulnerable residents at risk for further abuse.

Inspectors wroteBased on observations, record review, and interviews, and facility policy review, the facility failed to ensure a resident's dietary food allergies were followed for one of four residents (Resident (R) 8) reviewed for food allergies in a total sample of 15 residents. The facility served R8 food that was included in her medical record and on her diet card that she was allergic to. The facility's failure to follow their two step method of verification process to prevent a resident from receiving food items included on the allergy list could have resulted in a mild to severe food allergy for the resident.

Inspectors wroteBased on interview and record review, the facility did not ensure residents' advanced directives were implemented. This was observed with 2 (R102 and R24) of 2 residents reviewed for advanced directives. The failure to implement advanced directives has the potential to affect all 82 residents in the facility. * R102 elected a DNR (Do Not Resuscitate) status, and the paperwork was not processed as required. The facility did not honor R102's request and R102 received CPR on [DATE]. * R24 completed paperwork to request a Do Not Resituate (DNR) status and the facility did not honor this request and performed Cardiopulmonary Resuscitation (CPR). The facility's failure to honor residents' advance directives requesting no CPR created a finding of Immediate Jeopardy that began on [DATE]. [...]

Inspectors wroteBased on observation. interview, and record review the facility did not provide care consistent with standards of practice by failing to ensure changes in medical conditions were immediately addressed. This was observed with 2 (R24 and R17) of 18 resident record reviews. *R24 received fish for lunch and has a documented allergy to fish. After consuming some of fish R24 experienced a low heart rate and became unconscious. Staff failed to administer anaphylaxis interventions immediately. Staff texted R24's Medical Doctor (MD)-X with the observed change in condition and did not call for consultation. R24 passed away due to allergic reaction to the fish. The facility's failure to identify an allergic reaction to fish and to administer anaphylaxis interventions immediately created a finding of Immediate Jeopardy that began on 3/15/26. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure a resident's food allergy, once identified, was thoroughly assessed to determine how best to manage the resident's allergy and to ensure the resident did not receive food to which the resident was allergic. This was observed with 1(R24) of 1 resident experiencing a food allergy response.*R24 had a documented allergy to fish. R24 was served fish for lunch on 3/15/26 and experienced an anaphylactic response that was not identified and treated as anaphylaxis and R24 passed away at the facility. This created a finding of Immediate Jeopardy that began on 3/15/26. Nursing Home Administer (NHA)-A and Director of Nurses (DON) -B were notified of the Immediate Jeopardy on 3/26/26 at 10:40 AM. The Immediate Jeopardy was not removed at the time of exit on 4/6/26.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing or worsening for 1 (R98) of 5 residents reviewed for pressure injuries.*R98 was assessed on admission to be at risk for the development of pressure injuries. R98 developed an avoidable, unstageable pressure injury to the coccyx. R98's admission wound assessment completed on 3/5/26 documented a Stage 1 wound to R98's coccyx. R98's baseline care plan documented a barrier cream intervention with no further instructions for use and no other interventions in place to prevent pressure injury decline. Wound MD-BB was not made aware of the stage 1 wound to R98's coccyx on admission. [...]

Inspectors wroteBased on interview and record review the facility did not implement an effective Infection Control program to prevent the spread of infection. This includes infection surveillance, tracking and outbreak investigation. This has the potential to affect all 82 residents in the facility.*The Infection Preventionist (IP) did have documentation of infection surveillance logs with tracking for the last 3 months.* The IP did not have documentation of a covid outbreak to determine etiology and implementation of preventative measures. CROSS REFERENCE F883 and F887Findings include:1.) On 3/25/2026, at 11:03 AM, Surveyor requested infection control documents from Assistant Director of Nurses (ADON) -C, the facility designated Infection Preventionist, IP-DD is currently out of the facility. IP-DD started in this role in January 2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food was prepared and served in accordance with professional standards for food service safety potentially affecting the residents on the third floor and 7 residents who are on a pureed diet. Cook-L served residents on the third floor and was observed to touch with gloved hands food as it was being plated after touching other unclean surfaces. The food served from the steam table was not temped prior to serving to ensure the food was held at an appropriate temperature. Cook-L pureed the lunch meal without following the guidelines for the correct consistency of having a smooth texture; the pureed taco meat was the consistency of thin, watery gravy and the pureed mixed vegetables were thick and clumpy.

Inspectors wroteBased on record review and interview, the facility did ensure residents were offered the pneumococcal and influenza vaccines, along with the risks and benefits of the vaccines, upon admission. This was observed with 5 (R17, R5, R35, R7 and R6) of 5 residents immunization review.*R17 was admitted to the facility on [DATE] and is [AGE] year. R17 received PPSV (pneumococcal polysaccharide vaccine) 23 in 2017. R17 had no documentation upon admission for PCV (pneumococcal conjugate vaccine) 15, PCV 20 or PCV21. * R5 was admitted to the facility on [DATE] and is [AGE] year. R5 received PPSV 23 in 2019. R5 had no documentation upon admission for PCV 15, PCV 20 or PCV21. * R35 was admitted on [DATE] and is [AGE] year. There is no documentation, of any pneumococcal and influenza vaccines, in their medical record.* R7 was admitted on [DATE] and is [AGE] year. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the environment was homelike and did not impose a safety risk for 1 (R94) of 24 residents reviewed for the environmental concerns. R94's room had a large opening in the wall from a panel being removed exposing the internal aspect of the wall.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure PRN (as needed) orders for psychotropic medications had a documented rationale for extending the use beyond 14 days and indicate the duration of the PRN order for 1 (R17) of 5 residents reviewed for unnecessary medications. R17 had an order for clonazepam, an antianxiety medication, 0.25 mg every 12 hours as needed for anxiety initiated on 12/16/2025 with no stop date. The clonazepam was discontinued on 3/1/2026 and reordered on 3/2/2026 with no stop date.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R107 and R82) of 6 residents reviewed for allegations of abuse was had the allegation reported to the State Agency and local law enforcement within the required timeframe. *On 1/24/26, at 7:55 PM, R107 alleged Certified Nursing Assistant (CNA)-CC pushed R107 down and R107 hit their head on the wall. The facility reported the abuse allegation for R107 to the State Agency on 1/25/26, at 10:56 AM. The facility did not submit the initial allegation of abuse to the State Agency within 2 hours as required. *On 1/29/26, the facility became aware that R82 was found with a right femur fracture after she was admitted to the hospital for complaints of right leg pain. R82 was unable to state how the injury occurred. [...]

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R107) of 1 residents reviewed for discharge had the discharge summary documented in the resident's medical record. R107 was discharged from the facility on 1/25/26, and the facility did not have a discharge summary for R107's facility stay.

Inspectors wroteBased on interview and record review, the facility did not ensure the Minimum Data Set (MDS) assessment was accurate for 3 (R17, R7, and R13) of 18 sampled residents. *R17's Quarterly MDS assessment dated [DATE] did not document the need for dialysis or antiplatelet; anticoagulant was documented when R17 did not receive an anticoagulant. *R7's Annual MDS assessment dated [DATE] did not document R7 was a current tobacco user; R7 regularly smoked. *R13's Quarterly MDS assessment dated [DATE] documented R13 used a restraint in a chair less than daily, a motion sensor alarm less than daily, and a wander/elopement alarm less than daily; R13 did not use any restraints.

Inspectors wroteBased on interview and record review, the facility did not ensure a baseline care plan was developed and implemented within 48 hours of a resident's admission for 3 (R10, R98, and R35) of 4 residents. *R10's baseline care plan for post-traumatic stress disorder was not completed within the required 48-hour timeframe. *R98's baseline care plan for risk for pressure injury/skin integrity was not thoroughly completed within the required 48-hour time frame. *R35's baseline care plan for anticoagulant, antidepressant, diuretic, and antipsychotic was not completed within the required 48 hours timeframe.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure the residents' environment was free of accident hazards and residents received adequate supervision and assistance devices to prevent accidents for 2 (R7 and R106) of 4 residents reviewed for accidents. R7 was observed to be smoking outside the facility and was not comprehensively assessed whether she was safe to be smoking unsupervised and if she could hold onto her own smoking materials. The facility did not develop a care plan addressing R7's wishes to smoke, including interventions for her to do so safely. R106 was assisted to the floor during a transfer with one Certified Nursing Assistant (CNA) from the shower chair to the wheelchair. [...]

Inspectors wroteBased on observation, record review and staff interviews, the facility did not ensure they provided services to help maintain acceptable nutritional parameters for 1 (R6) of 3 residents reviewed for significant weight loss. R6 experienced a significant weight loss in January 2026. The facility's response was to obtain weekly weights so they could closely monitor R6's nutritional status. The facility did not obtain weekly weights, therefore could not comprehensively assess R6's weights and implement interventions to address R6's weight concerns. Evidenced by:Policy review: Weight Monitoring; revision date 11/20/23. Policy: [...]

Inspectors wroteBased on record review, staff and resident interviews, the facility did not ensure pain management was provided to 1 (R7) of 2 residents reviewed for pain, in accordance with the resident's goals and preferences and with the comprehensive person-centered plan of care. R7 experienced an increase in pain due to the discontinuation of medication, and the facility did not comprehensively assess R7's increased pain and update the plan of care with interventions that may decrease R7's pain level and frequency. Evidenced by: R7 was admitted to the facility on [DATE] with diagnosis that included Fibromyalgia, Anxiety Disorder, Major Depressive Disorder, and Rheumatoid Arthritis (multiple sites). R7 was admitted for rehabilitative services and was receiving physical and occupational therapy. A review of the physician orders for R7 noted the following:*NURSING ORDER PAIN MED MONITORING: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R10) of 3 residents reviewed for post-traumatic stress disorder (PTSD) received trauma informed care in accordance with professional stands of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. R10 was admitted to the facility with a diagnosis of PTSD. The facility did not complete a trauma assessment or develop a person-centered care plan identifying triggers, interventions, or monitoring for R10's PTSD.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food served was palatable, attractive, and at a safe and appetizing temperature for 1 (R8) of 1 resident reviewed for pureed diet. R8 was served a pureed meal consisting of taco meat and mixed vegetables. The pureed taco meat was a tan liquid, and the pureed mixed vegetables were green and chunky. R8 complained of the food being cold and after the plate was microwaved, R8 spit out the food and refused to eat it due to the taste. No other foods were offered to R8 after the refusal of the main course.

Inspectors wroteBased on record review and interview, the facility did not ensure residents were offered the covid vaccine, along with the risks and benefits. This was observed with 3 (R35, R7 and R6) of 5 resident immunization reviews.*R35 was admitted to the facility on [DATE]. There is no documentation R35 was offered the covid vaccine, along with risks and benefits, upon admission.*R7 was admitted to the facility on [DATE]. There is no documentation R7 was offered the covid vaccine, along with risks and benefits, upon admission.*R6 was admitted to the facility on [DATE]. There is no documentation R6 was offered the covid vaccine along with risks and benefits, upon admission.

Inspectors wroteBased on interviews, document review, and review of the facility policy, the facility failed to ensure narcotic counts were initialed by two nurses on all three shifts (7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM) at the change of shift to ensure the narcotic count was accurate for six of six medication carts reviewed. This failure had the potential for drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety potentially affecting all 74 residents that eat food prepared by the facility. * In the facility's main kitchen, observations of partially used and undated food were observed in the walk-in cooler. Food items observed in the facilities main kitchen's cooler were open to air. Open food was observed in the fridge on the 4th floor with no open or use by date. * [NAME] and hair restraints were not being utilized by kitchen staff, while they worked in the kitchen areas. * A large white scoop was observed in a bin holding sugar granules and not in the holder.

Inspectors wroteBased on interview and record review, the facility did not ensure 34 staff received annual N95 respirator fit testing. Surveyor reviewed the facility's infection control program. On 1/21/25 at 8:27 a.m. Surveyor received a list of staff with the dates of their last N95 fit test. Surveyor noted staff members were overdue for their annual fit test.

Inspectors wrote2.) R18 was readmitted to the facility on [DATE] with a diagnoses include ankylosing spondylitis of unspecified sites in spine, obstructive sleep apnea, and major depressive disorder. R18's Significant Change Minimum Data Set (MDS) with an assessment reference date of [DATE] indicated R18 had a Brief Interview for Mental Status score of 15 (cognitively intact). R18 makes decisions for themselves. R18's MDS was marked as R18 having no behaviors during the look back period and always being incontinent of bowel and bladder. R18's physician orders dated [DATE] documents: Trazodone 50 mg (milligram) tablet as needed (PRN) every 24 hours was prescribed. Surveyor noted that R18's Trazadone physician's order did not have a stop date for the PRN medication. The order was not in place during R18's previous stay at Facility. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure the communication of services between hospice and the facility for 2 (R9 & R43) of 3 residents reviewed for hospice care. The required hospice election statement, admissions agreement, recertification orders, communication notes from hospice nurses or certified nursing assistants were not available to the facility staff in the hospice binder or resident's medical records. * R9 was placed on hospice 8/3/24. Hospice provided no access to R9's hospice charting to facility staff, until Surveyor informed facility staff that all the documentation required by hospice was not found in the hospice binder or medical record for R9. The only document observed by the Surveyor in the hospice binder for R9 was a plan of care dated 9/4/24. *R43 was placed on hospice on 12/20/2024. [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice to administer medications as ordered for 1 (R1) of 1 residents. R1 received one tablet of Hydrocodone-Acetaminophen 5-325 mg (milligrams) prior to going to dialysis on 10/2/24. According to R1's physician orders, R1 should have received two tablets of Hydrocodone-Acetaminophen 5-325 mg.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 3 sampled residents (R2) was free from significant medication errors. * R2 received a medication, Morphine, on 05/26/2024, which is not on R2's Medication Administration Record (MAR) and is not prescribed to R2. After administration, this medication required close monitoring of R2's physiological status. *R2 had orders for Clonazepam, oral tablet, 0.5mg to be given two times per day (AM and PM) for Anxiety. On 05/21/2024, R2 received 1 mg of Clonazepam during the PM medication pass instead of 0.5mg as prescribed.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents and evaluate and analyze the risks and eliminate them for 1 of 4 (R61) residents reviewed for accidents. * R61 sustained 2 falls in which the facility identified toileting or need for toileting as the root cause. A thorough investigation of the falls was not completed as to when R61 was last seen or toileted and there was no evidence the facility completed a B&B (bowel and bladder) assessment to determine R61's toileting needs, or possible pattern of toileting needs. R61 sustained a 3rd fall resulting in rib fractures and a head injury requiring staples.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (R55) of 4 residents reviewed for nutrition and hydration had their nutritional care needs recognized, evaluated, and addressed to provide adequate parameters of nutritional status. * R55 was admitted to the facility on [DATE] weighing 122.5 lbs. R55 was put on weekly weights on 8/6/23 and weighed 118.0 lbs. on 8/14/23. The week of 8/20/23, R55's weight was not taken. Next weight taken was on 8/28/23 and was 111.0 lbs. noting a 11.5 lbs. or 9.4% loss in 3 months. Assistant Dietician (AD)-R assessed resident on 8/30/23 and used the previous weight of 118.0 lbs. and did not note the significant weight loss. The week of 9/5/23, R55's weight was not taken. Next weight taken was on 9/11/23 and was 105.0 lbs. noting a 16.5 lbs. or 13.5% loss in 3.5 months. [...]

Inspectors wroteBased on observation, record review and staff interviews, the facility did not always ensure that they stored, prepared and served food in accordance with professional standards for food service safety. This was observed in the main kitchen and 2 out of 3 unit kitchenettes. This had the capability of affecting all 69 residents based on the total census of 10/23/23. Surveyor made observations of the main kitchen as well a 2 smaller servings kitchens located on the 2nd and 5th floors. Observations were made of kitchen equipment such as ovens, meat slicer, stand mixer and coolers that had many areas of dried spillage and debris. Coolers located in the main kitchen container expired foods and foods that did not contain a label or date. [...]

Inspectors wroteBased on interview and record review the facility did not follow its water management plan control measures which could affect all 69 residents residing in the facility. *The facility's water management plan did not address the second-floor closure as dead legs. The facility was flushing the second-floor faucets and running the toilets monthly; however, the facility follows the American National Standards Institute/American Society of Heating, Refrigerating and Air Conditioning Engineers, Inc (ANSI/ASHRAE) Standards which recommend flushing dead legs at least weekly. The facility water management plan states to inspect Hammer Arrestors in the facility's laundry room and mechanical room annually. There is no documentation regarding the last time the Hammer Arrestors were inspected. The Hammer Arrestor log was blank. [...]

Inspectors wroteBased on observation, record review and staff interviews, the facility did not always ensure that they followed the posted menus and meet the nutritional needs of residents who required an alternative diet texture on 1 out of 3 units (3rd floor) . The facility did not provide the posted menus items during the lunch observation on 10/24/23. In addition on 10/24/23 during the lunch meal those residents who required an alternative texture for meal consumption were not provided with all of the listed menu items. This is evidenced by: On 10/24/23 at 12:15 p.m., Surveyor made observations of the lunch meal service on the 3rd floor. At this time, Dietary Aide (DA)- G was the only dietary staff working in the kitchenette area as food began to arrive to the unit via the service elevator from the main kitchen. At 12:25 p.m., a large kettle of soup arrives to the unit. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that staff promptly consulted with a physician when residents experienced significant changes of condition for 1 (R48) of 4 residents reviewed for change of condition. R48 had change of condition with a high blood pressure (BP). Medical Director (MD)-P was updated and instructed staff to monitor BPs. The nurse did not inform MD-P of the consistently high BPs.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that residents who entered the facility with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 5 (R17) residents reviewed for limited range of motion and mobility. R17 had orders for Restorative Nursing to ambulate with parallel bars which was not implemented and followed.