Jewish Home & Rehab Center D/P SNF

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents (Residents 2 and 332) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when:1. For Resident 2, there was no specific target behavior monitoring for the use of Olanzapine (an antipsychotic medication).2. a. For Resident 332, the order for Lorazepam (medication used to treat anxiety) PRN (as needed) did not have a stop date, and b. Lorazepam PRN was administered without behavior exhibited. These deficient practices had the potential for Residents 2 and 332 to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being.1. [...]

Inspectors wroteBased on interview and record review, the facility did not send notification to Ombudsman when two of three residents (Resident 1 and Resident 2) were transferred out to acute. This failure has potential for residents not having the right to appeal when necessary. During a record review on 2/12/26 at 10 AM, Resident 12's admission Record dated 2/12/26, indicated, was admitted on [DATE] with diagnoses including: [...]

Inspectors wroteBased on interviews and record review, facility staff failed to provide pressure injury services for one of three sampled residents, Resident 1. The facility failed to:1. Accurately monitor and evaluate Resident's 1's pressure injuries. 2. Revise treatment plans to promote healing of pressure injuries (any lesion caused by unrelieved pressure that results in damage to the underlying skin- see full definition below). 3. Evaluate and monitor the impact of interventions to prevent new pressure injuries from developing. 4. Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environmrnt of one of one sampled resident (Resident 1) was free of potential accident hazards (falls and injuries from a lift) when they transferred Resident 1 in a lift to a commode and left her hanging a foot above the commode for several hours several times per day rather than lowering her to the toilet seat of the commode as instructed in the manual from the manufacturer (Invacare). Although Resident 1 chose this procedure and staff came to check on her while she was hanging from the lift, this does not prevent: the lift from failing; Resident 1 from falling; Resident 1 from injury; the facility from responsibility for Resident 1's safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to report three of 11 allegations of abuse within two hours, to the California Department of Public Health (the Department). This failure had the potential to leave residents vulnerable to further abuse. 1. Two intakes of the same allegation, sent 2 different dates. Cross reference to Incident 2303945 (CA0092790) and 2303946 (CA00928621) A review of Form SOC 341 Report of Suspected Dependent Adult/Elder Abuse with completed date 10/31/24, indicated, Resident 1 alleged that two Certified Nursing Assistants (CNAs) were handling him roughly while changing his bedsheets on 10/29/24 .nurse conducted skin and pain assessment .denied any pain and no noted skin injury .Both CNAs were immediately suspended pending investigation. [...]

Inspectors wroteBased on interview and record review, the facility failed to report the result of investigations to the State Survey Agency (SSA) within 5 working days of the incident for four (4) of 12 residents' (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) abuse allegations .Resident 1 alleged 2 CNAs rough handling during change of bedsheet on 10/29/24Resident 2 alleged 1 CNA on 11/5/24 was aggressive and said get up by yourself, walk by yourselfResident 3 alleged a nurse on the night of 8/27/24 was rude, harsh, and hit her. Resident 5 went to Resident 4's room, grabbed his face and pushed it back. This failure may cause delay in taking all necessary actions to protect the residents and prevent further occurrences.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of three sample residents (Residents 1, 2, and 3) were free from neglect. All three residents were dependent on staff for transfers and ADL (Activities of Daily Living) and all three residents reported their unit was short staffed, resulting in long wait for services. These episodes may have resulted in: 1. Resident 1 expressing feelings helplessness, frustration and discomfort when: Resident 1 waited for four hours in her wet briefs before staff cleaned her and changed the brief; was left on the commode for 1.5 hours; was not repositioning by staff in a timely manner which caused her discomfort; Resident 1 expressing feelings of frustrations, abandonment, and being suicidal. 2. Resident 2 saying she was in pain at night after staff did not put her to bed in a timely manner. [...]

Inspectors wroteBased on interview and record review, the facility did not report allegations of neglect for Resident 1, one of three sample residents. Resident 1 sent four emails to the facility alleging sub-par quality of care issues such as: delayed response to request for care, no care, not getting enough food and water, and getting minimal care. This has the potential to place Resident 1 and other residents at risk for abuse/neglect.

Inspectors wroteBased on interview and record review, the facility did not provide the necessary care to maintain the highest practicable mental and psychosocial wellbeing for Resident 1, one of three sample residents. Resident 1 was totally dependent on staff for Activities of Daily Living (ADL) and other care needs. Starting July 2024, the facility unilaterally reduced direct care giver hours by 41.67% to Resident 1. This resulted in Resident 1 expressing feelings of frustrations, abandonment, and suicidal ideation.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a sanitary kitchen when: 1. A rodent dropping was found under the cooking line (area in the kitchen where multiple pieces of cooking equipment are in a line), this area had a build-up of food, black grime and trash. 2. Multiple areas in the kitchen on the floor under equipment, there was old food, trash and black grime. 3. The ice machine had a black grime build-up on the area above the ice grates where water flows to fill up the grates. 4. Utensils were stored with a build-up of old food. 5. The refrigerator utilized to store food for activities was food crumbs and spills and expired foods. 6. Multiple floor drains in the kitchen had a build-up of old food and grime. 7. The dating system in the walk-in refrigerator was not accurate and readable. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their fall policy and procedure for three of 6 sampled residents (Resident 187, 327, and 356) when: 1. There was no evidence of post fall interdisciplinary team (IDT, a group of healthcare professionals from different fields who work together to provide the best care for a patient) meeting for Resident 187. 2. There were no consent for video monitoring and evidence of post fall IDT meeting for Resident 327. 3. There was no post fall assessment and completed IDT meeting note for Resident 356. These failures could potentially result in negative outcomes for Resident 187, 327, and 356.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 8/20/24 and 8/21/24, four medication errors were observed out of twenty-six opportunities for three out of six residents, resulting in an error rate of 15%. This failure had the potential to result in harm in the health and safety of residents.

Inspectors wroteBased on observation, interview, and document reviews it was found that the facilities' Quality Assessment Performance Improvement (QAPI) program was ineffective. Despite its purpose to proactively identify and prevent medication administration errors, it fell short. This was evident during a medication pass observation conducted during the survey, which revealed multiple medication errors related to eye drops (See F759).

Inspectors wroteBased interview and record review, the facility failed to provide two of three residents, Resident 177 and Resident 248, with SNF-ABN (Skilled Nursing Facility Advanced Beneficiary Notice).

Inspectors wroteBased on interview and record review the facility failed to recognize and report an allegation of abuse for one out of six sampled residents (Resident 372) when Resident 372 reported to Social Worker (SW) 1 an allegation of verbal abuse by nursing staff and Physical Therapist (PT) 1, yet it was not reported to the facility administrator or other necessary agencies. This failure has the potential for allegations of abuse that may be substantiated to not be properly corrected and keep residents at risk for continued exposure to abuse.

Inspectors wroteBased on interview and record review the facility failed to recognize and investigate an allegation of abuse for one out of six sampled residents (Resident 372) when Resident 372 reported to Social Worker (SW) 1 an allegation of verbal abuse by nursing staff and Physical Therapist (PT) 1, yet it was not thoroughly investigated by the facility. This failure has the potential for allegations of abuse that may be substantiated to not be properly corrected and keep residents at risk for continued exposure to abuse.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess hearing for one out of two sampled residents (Resident 356) when Resident 356 was assessed as not having hearing aids when they used hearing aids on admission to the facility. This failure has the potential for Resident 356's needs to not be met due to their communication and hearing needs not being accurately assessed.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and specific interventions for 1 of 35 sampled residents (Resident 327) when: 1. Care plan was not developed to address urinary tract infection (UTI, a common infection that occurs when bacteria enter the urinary tract and cause inflammation). 2. Fall care plan interventions were not implemented. These failures had the potential for not meeting Resident 327's nursing needs and goals to attain the resident's highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update care plans for three of 35 sampled residents (Resident 327, 187, and 264) when: 1. Fall care plan was not updated for Resident 187 after her falls on 2/15/24, 3/23/24, and 8/2/24. 2. Fall care plan was not updated for Resident 327 after her falls on 6/30/24, and 8/21/24. 3. Care plan for pain was not updated for Resident 264. These failures had the potential to put the residents at risk of not receiving appropriate cares.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident's assistive hearing device was functioning in one of two sampled residents (Resident 356) when Resident 356 reported that their hearing aid had been broken for multiple days and clinical staff were not aware of it. This failure has the potential to result in the residents' needs not being met due to a reduction in their ability to hear and communicate.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safety to prevent fall related injuries to one of one sampled resident (Resident 250) when a volunteer transported Resident 250 using a wheelchair. The facility failure resulted to Resident 250 to sustain a laceration (a tear on the skin) to the forehead, a fracture (a break in the bone) on the second cervical (neck) spinal bone (C2 dens fracture), and a fracture along the ulnar base of the first proximal phalanx of the left hand (a finger on the left hand).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control program and practices designed to help prevent the development and transmission of diseases and infections when: 1. Certified Nursing Assistant (CNA) 1 did not perform hand hygiene between Resident 327 and Resident 289 in the dining room in G ([NAME] Building) 2. 2. The facility failed to maintain 6 out of 6 wash machines per manufacturer's recommendation. These failures had the potential for spread of infection to residents and staff.

Inspectors wroteThe facility failed to maintain equipment in safe operating condition when reach-in refrigerator #7 had condensation inside the refrigerator that was dripping on food. This had the potential to contaminate food and cause food-borne illness to 332 out of 338 medically compromised residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement pressure ulcer care plan for one of 3 sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 did not reposition Resident 1 every 2 hours on 5/1/24. This failure had the potential to delay the healing of the pressure ulcer for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 3 Certified Nursing Assistants (CNA) 1 was competent when CNA 1 did not know Resident 1 had dementia and urinary tract infection (UTI, a collective term that describes any infection involving any part of the urinary tract, namely the kidneys, ureters, bladder and urethra). This failure had the potential to result in Resident 1 not receiving appropriate treatments and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure to explain the skills and techniques when two out of 4 sampled certified nursing assistants (CNAs) did not know how to apply Purewick (a female external catheter designed to provide a non-invasive option for the management of urinary incontinence in women) to residents. This failure of not having competent skills and techniques puts all residents at risk for getting wet when using Purewick.

Inspectors wroteBased on interview, and record review, the facility failed to revise the constipation care plan for one of 4 sampled residents (Resident 2) when there was no evidence that the care plan (CP) was updated after [DATE] when Resident 2 returned from the hospital with constipation on CT (a noninvasive medical examination or procedure that uses specialized X-ray equipment to produce cross-sectional images of the body). This failure had the potential to put Resident 2 at risk of not receiving appropriate care timely.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the physician of result that falls outside of clinical reference ranges for one of 4 sampled residents (Resident 2) when there was no evidence if the nurse notified the physician between 6/17/23 and 6/19/23 of the X-ray result, dated 6/16/23. This failure had the potential to delay appropriate care and treatment for Resident 2.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide an environment free of accident hazards when Resident 1 (one sampled resident), spilled a cup of hot water onto her chest, left hand, and left thigh, and suffered 2nd degree burns from the hot water. The facility failed to provide adequate supervision to prevent an avoidable accident.

Inspectors wroteBased on interview and record review, the facility failed to implement its care plan intervention of hourly rounding (checking in with a patient once every hour to proactively address needs) for one of four sampled Residents (Resident 2) after a substantiated claim of resident-to-resident abuse. This failure has the potential to result in Resident 2 ' s continued behavioral issues and puts Resident 2 and other residents at risk for abuse.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Certified Dietary Manager (CDM), the position responsible for supervision of daily foodservice operations, was fully qualified when he did not have six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming his full-time duty at the facility. This failure had the potential for inadequate supervision of the dietary department for 337 residents who ate food from the kitchen out of a census of 337.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the resident or family group views were considered and acted upon grievances and recommendations, when not all residents were invited to have participated in resident council monthly meeting. This failure had the potential to result to ineffective residents' consensus-building.

Inspectors wroteBased on observation and interview, the facility failed to ensure current survey results were readily available to residents for every unit for three of three observations of the facility survey report book, which had the potential to affect all residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were made aware and/or educated on how to voice grievances to either the facility or other agency that hears grievances without fear of discrimination or reprisal, and that prompt efforts were made to resolve grievances the resident may have. This failure had the potential to affect resident's right to voice their concerns and have any grievance be acknowledged and processed by the facility in a timely manner.

Inspectors wroteBased on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, two medication errors were observed out of twenty-seven opportunities, resulting in an error rate of 7.41%. 1. A review on 6/21/23 of Resident 120's physician's orders indicated (Timolol maleate 0.5% eye gel forming solution, 1 drop both eyes ) Timolol is a medication used to treat glaucoma. Glaucoma is a condition when there is too much pressure in the eye. This pressure can be bad for your eyes because it can damage the delicate parts inside. During an observation on 6/21/23 at 7:52 am, LVN 1 was observed administering Timolol solution to Resident 120. It was noted that the resident's left eye was closed when the eyedrop was instilled. Resident 120 did not receive the Timolol eye drop in her left eye. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage when: 1. There was an undated blueberry sauce container in the refrigerator in the kitchen. 2. There was an expired crushed red pepper container in the kitchen. 3. There were undated individual condiments (such as Smucker's Strawberry Jam, Smucker's Sugar Free Blackberry Jam, Smucker's Pure Honey, Smucker's Sugar Free Breakfast Syrup and Jif Creamy Peanut Butter) in the original undated bottom of cardboard box containers in the storage room in the kitchen. These failures had the potential to put residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain effective infection prevention and control program when: 1. Nasal cannulas (a device used to deliver supplemental oxygen) were not covered and had no information on replacement or discard dates for 6 residents (Resident A, Resident B, Resident C, Resident 10, Resident 44, and Resident 210). 2. Extended use of N-95 respirators and face shields were stored in the same paper bags. 3. Trash containers in the clean and dirty areas of the laundry department had no lid covers. 4. There was no evidence of preventive maintenance for washers, dryers and [NAME] used in the laundry department. 5. Nebulizer masks were not covered and labed for Residents 44 and 19. These failures had the potential to result to spread infections among staff, residents, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 334) of three residents reviewed for personal inventory form was completed and signed. This failure had the potiental to result in theft or loss of resident's personal effects.

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive, person-centered care plan for Resident 189's use of Olanzapine (an antipsychotic medication) when the care plan did not indicate target behavior/s and known or common side effect/s for which the medication was used for. This failure had the potential to not ensure the medical, nursing, mental and psychosocial needs are identified, addressed, and/or met by the resident, and monitored by staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of accident hazards when one (Resident 245) of three residents' electrical appliances were not approved by underwriters laboratories (UL, accepted certification mark for safety standards).

Inspectors wroteBased on interview and record review, the facility failed to ensure medically-related social services was provided to Resident 42. This failure had the potential to not ensure appropriate social services were provided to help attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation and review of records, it has been determined that the facility did not ensure the accurate administration of all drugs and biologicals for one of three residents under review. Specifically, during the administration of an insulin injection to Resident 201, it was observed that the injection was administered on the same site, which could have potentially led to adverse medication consequences.

Inspectors wroteBased on interviews and record reviews, it has been determined that the facility's pharmacist neglected to report medication irregularities concerning two residents (201 and 39). This failure had the potential to lead to undetected medication irregularities.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 72) of three residents reviewed remained free from unnecessary medications when Resident 72 did not have specific behavioral monitoring for the use of zyprexa (antipsychotic, to reduce psychosis-related symptoms). This failure had the potential to result to medication adverse effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. There was a specific condition, diagnosis, and/or indication for use for Resident 189's Olanzapine (an anti-psychotic medication) medication. 2. There was monitoring of targeted behaviors for Resident 189's Olanzapine medication. These failures could result in unnecessary use of, ineffective and/or lack of monitoring for an anti-psychotic medication that could negatively affect the resident's highest practicable mental, physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when there were no lids on two out of nine garbage containers in the loading dock. This failure had the potential to result to spread of infections among residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were maintained for one of three residents reviewed, when there was no informed consent for Resident 189 completed for use of olanzapine (an antipsychotic medication.) This failure had the potential to not provide sufficient information that reflected the residents' condition, care and services provided, and to not ensure information is available to staff and/or other individuals who may use and/or need it to facilitate communication.

Inspectors wroteBased on interview and record review, the facility failed to ensure policies and procedures were followed for pneumococcal vaccination when medical records for one of five sampled residents (Resident 271) did not have documentation that the resident received pneumococcal immunization. This failure did not ensure the risk for acquiring, transmitting, or experiencing complications from pneumococcal disease was minimized for Resident 271.