Jordan Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy it was determined the facility failed to follow the care plans for 1 of 3 sampled residents, Resident (R) 4. Resident 4 was identified as requiring a mechanical lift for transfers on her care plan. On 05/21/2026, during interview with Licensed Practical Nurse (LPN) 1, she stated CNA8 and CNA9 transferred R4 to the bed without using a mechanical lift on 05/08/2026.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure each resident's right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 6 of 28 sampled residents, Resident (R) 7, R9, R10, R28, R76, and R82. Review of each resident's document Behavior Modification Consent revealed the name of the medication, risks and benefits of the medication, and treatment alternatives/options were not specified.

Inspectors wroteBased on observation, interview, record review, information from the Centers for Disease Control and Prevention (CDC), and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 40 sampled and supplemental residents, Resident (R) 66, R77, R35, R13, R42, R71, and R33. R66 was diagnosed with a communicable skin infection on 04/10/2026 and a contact precautions order was placed by the physician. However, observation on 04/14/2026 revealed no transmission-based precaution signage posted outside R66's room, and after Contact Precaution signage was posted, staff entered the room without donning (putting on) required personal protective equipment (PPE). [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's job description, and review of the facility's document and policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 9 sampled residents, Resident (R) 10, R17, and R28, related to falls.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to provide necessary activities of daily living care to maintain 1 of 2 sampled dependent residents in a clean manner, Resident (R) 11. The facility failed to ensure R11 had clean clothing, clean bed linens, and grooming assistance.

Inspectors wroteBased on observation, interview, record review, review of the Activity Director job description, and review of the facility's policy, the facility failed to provide an ongoing program to support the residents' choice of activities based on their comprehensive assessment, care plan, and preferences, specifically one-to-one interaction, as directed for 2 of 2 sampled residents, Resident (R) 12 and R13. Observations from 04/14/26 through 04/16/2026 revealed R12 and R13 were in bed, dressed in bed clothing or a shirt only. No observations were made of staff providing one-to-one interaction.

Inspectors wroteBased on observation, interview, review of the facility's daily bedtime snack list, and review of the scientific article referenced by the National Institute of Health (NIH), the facility failed to provide substantial snacks to residents who needed assistance at meals as determined by review of the time between supper and breakfast was greater than 14 hours. Review of the facility meal service times, not dated, revealed total assist residents received supper at 4:30 PM and breakfast at 7:00 AM.

Inspectors wroteBased on observation, interview, review of the United States Department of Agriculture (USDA) web site, and review of the facility's policies, the facility failed to store and serve food in a safe manner as determined by observations during the initial tour on 05/02/2025. These observations revealed food not labeled or dated in the dry storage, walk-in refrigerator, and the freezer. In addition, observations of the supper meal tray line on 06/02/2025 at 4:16 PM revealed the Dietary Manger and [NAME] improperly used the food thermometer, and Dietary Aide 1 used open utility carts with a wet top shelf. This had the potential to affect 92 residents that received food from the kitchen.

Inspectors wroteBased on interview, record review, review of the Postal Service Reform Act of 2022, and review of the facility's policy, the facility failed to ensure residents the right to receive mail, letters, and packages delivered to the facility. In interviews with Resident Council members, they stated they did not receive mail on Saturdays. This practice had the potential to affect all current 92 residents.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 1 of 24 sampled residents, Resident (R) 81. R81's Comprehensive Care Plan (CCP) stated his preference for individual activities. It did not, however, reflect any history of service-related, post-traumatic stress disorder (PTSD) potential triggers, or how to address them.

Inspectors wroteBased on observation, interview, record review, and review of the U.S. Food and Drug Administration's (FDA) guidelines, the facility failed to ensure the resident environment remained as free of accident hazards as was possible to ensure the safety of 1 of 5 residents reviewed for vaping safety. Observation on 06/02/2025 revealed R62 using a vape (e-cigarette) while wearing a nasal cannula that was delivering four liters of oxygen (O2) with R44 exposed to R62's second hand vaping aerosol.

Inspectors wroteBased on observation, interview, review of the manufacturers' directions for use (DFU), and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 24 sampled residents, Resident (R) 46. Observation on 06/03/2025 revealed R46's tube feeding, tubing, and continuous bladder irrigation tubing were left uncovered when disconnected from the resident.

Inspectors wroteBased on observation, interview, review of a Centers for Disease Control and Prevention (CDC) document, and review of the facility's policy, the facility failed to develop and implement effective policies to ensure the smoking safety for all residents that used electronic cigarettes (e-cigarettes or vapes) for 1 of 5 residents that used e-cigarettes, Resident (R) 62 and R44, who was exposed to R62's second hand vaping aerosol. Observation on 06/02/2025 at 2:50 PM revealed R62, with R44 present, using a vape while wearing a nasal canula that was delivering four liters of oxygen (O2), and the facility's vaping policy did not address oxygen use or the exposure risk of others to second hand smoke.