Robison Jewish Health Center

Inspectors wroteBased on interviews and record review it was determined the facility failed to ensure a Stage 2 pressure ulcer was identified, assessed, treated and monitored upon admission to the facility for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. As a result, Resident 1 experienced significant damage to her/his penis, which was unrepairable and resulted in the resident no longer being able to urinate from her/his penis.

Inspectors wroteBased on interview and record record it was determined the facility failed to monitor for legionella in 1 of 1 facility reviewed for infection control. This placed residents at risk for infection from exposure to water borne pathogens.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a system was in place to receive, track and resolve resident and/or resident representative grievances for 1 of 1 sampled facility reviewed for Resident Council. This placed residents at risk for unreported and unresolved grievances.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure physician orders were followed, and failed to identify, assess, and treat a change in a resident's skin condition for 3 of 9 sampled residents (#s 19, 84 and 87) reviewed for unnecessary medications and skin conditions. This placed residents at risk for adverse medication effects and untreated and worsening skin impairments.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure medications and biologicals were secured and only accessible to authorized persons for 1 of 4 Halls and 1 of 4 Households observed. This placed residents at risk for receiving unprescribed medications and drug diversion.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide occupational and physical therapy services as ordered for 3 of 4 sampled residents (#s 11, 22 and 89) reviewed for rehabilitation services. This placed residents at risk for a decline in functional abilities and diminished quality of life.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain a homelike environment with comfortable sound levels and exercise reasonable care for the protection of resident's property from loss for 2 of 3 sampled residents (#s 5 and 87) reviewed for environment. This placed residents at risk for lack of a homelike environment, lost sleep and lost personal property.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for experiencing adverse side effects of medication.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the state Long Term Care Ombudsman's office was notified of facility transfers or discharges for 2 of 2 sampled residents (#s 93, and 95) reviewed for hospitalization and discharge. This placed residents at risk for lack of advocacy.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for 1 of 2 sampled residents (#49) reviewed for position and mobility. This placed residents at risk for worsening contractures (a permanent tightening of the muscle, tendons and skin causing the joint to shorten and stiffen) and conditions.

Inspectors wroteBased on interview and record review it was determined, the facility failed to provide assistance with bathing for 1 of 3 sampled residents (#4) reviewed for bathing. This placed residents at risk of unmet care needs.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure residents received treatment and care according to professional standards of practice related to neurological checks after a fall for 2 of 3 sampled residents (#s 5 and 6) reviewed for falls. This placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were treated with dignity and respect for 1 of 2 sampled residents (#1) reviewed for dignity and respect. This placed residents at risk for decreased quality of life.

Inspectors wroteBased on interview and record review it was determined the facility failed to implement interventions to prevent a fall for 1 of 3 sampled residents (# 20) reviewed for accidents. This failure resulted in Resident 20 having a fall with serious injury including a head hematoma (a pool of blood under the skin), a gluteal hematoma, multiple rib fractures and skin avulsions (skin tears) which required emergency medical services and treatment at the hospital.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed ensure the ice machine was cleaned adequately to maintain sanitary conditions in 1 of 1 kitchen reviewed for sanitary kitchen services. This placed residents at risk of foodborne illness.

Inspectors wroteBased on observations, interviews and record review it was determined the facility failed to implement infection control practices for 18 of 18 residents (#s 2, 4, 5, 8, 9, 10, 11, 14, 18, 21, 25, 26, 27, 29, 31, 33, 34 and 36) and 1 of 4 staff (# 15) reviewed for infection control. This placed residents at risk for infection.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure drugs and biologicals were secured and not expired for 3 of 4 medication carts and 1 of 1 medication room reviewed for medication storage. This placed residents at risk for adverse medication effects.

Inspectors wroteBased on observations, interviews and record review it was determined the facility failed to develop and implement person centered care plans for 2 of 8 residents (#s 3 and 8) reviewed for falls and medications. This placed residents at risk for falls and adverse medication effects.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for medication administration for 1 of 5 residents (#26) reviewed for unnecessary medications. This placed residents at risk for medical complications.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure the residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter for 1 of 5 sampled residents (#8) reviewed for medications. This placed residents at risk for unassessed needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure expired COVID-19 immunizations were not administered to 2 of 11 residents (#s 19 and 36) reviewed for immunizations. This placed residents at risk for adverse immunization consequences.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to safely transfer a resident with the use of a mechanical device for 1 of 1 sampled resident (#301) reviewed for accidents. This failure resulted in Resident 301 falling during a transfer and was hospitalized with a subdural hematoma (a pool of blood between the brain and its outermost covering).

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure food was prepared and served under sanitary conditions for 1 of 1 kitchen reviewed for kitchen services. This placed residents at risk of cross contamination and foodborne illness.

Inspectors wroteBased on observation and interview it was determined the facility failed to provide a homelike environment for 1 of 4 units (200, 300, 400 and 500 units) reviewed for environment. This placed residents at risk for living in an unhomelike environment.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to comprehensively assess the dental health of 1 of 1 resident (#20) reviewed for dental care needs. This placed residents at risk of unmet dental needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide necessary care and services related to showering for 1 of 4 sampled residents (#2) reviewed for ADLs. This placed residents at risk for unmet hygiene needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to provide timely notification to a resident's physician of a missed seizure medication dose for 1 of 7 sampled residents (#151) reviewed for medications. This placed residents at risk for adverse consequences of missed medication doses, including seizures.

Inspectors wroteBased on interview and record review it was determined the facility failed to consistently assess pressure ulcers and notify the physician of a new pressure ulcer for 1 of 2 sampled residents (#47) reviewed for pressure ulcers. This placed residents at risk for worsening or delayed healing of pressure ulcers.

Inspectors wroteBased on interview and record review it was determined the facility failed to monitor nutritional parameters for 1 of 1 sampled residents (#47) reviewed for change of condition. This placed residents at increased risk of unplanned weight loss.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs in a timely manner for 2 of 8 residents (#s 2 and 40) reviewed for staffing concerns. This placed residents at risk for delayed and unmet care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from unnecessary bowel medications for 1 of 5 sampled residents (#7) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea.