Seven Acres Jewish Senior Care Services

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 22 residents (Resident #14, #21, and #80) reviewed for care plans. The facility failed to implement Resident #14's care plan intervention requiring a fall mat on the right side of the bed. Resident #14 experienced an unwitnessed fall and was found sitting on the floor on the right side of her bed without the fall mat in place. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, 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 3 out of 22 residents (Resident #45, Resident #99, Resident #1) reviewed for infection control. -The facility failed to follow their policy and procedure regarding infection control measures for prevention of candida auris (a type of yeast that can cause severe illness and spread easily among very sick patients in healthcare facilities). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure personal privacy for 1 of 5 residents (Resident #2) observed for medication administration in that: The facility failed to ensure MA A on 06/24/2026 provided Resident #2 privacy during medication administration. MA A administered medication to Resident #2 in the day area. This deficient practice could lead to psychosocial harm due to feelings of low self-esteem and/or embarrassment regardless of resident cognition.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 22 residents (Resident #12) reviewed for resident rights. -The facility failed to ensure Resident #12's call light and water pitcher were accessible to him while he was in bed on 6/23/26 and 6/24/26. This failure could place residents at risk of unmet needs, dehydration and feelings of helplessness.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 resident (Resident #80) reviewed for PASRR services. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the Long-Term Care (LTC) Online Portal within 20 business days following Resident #80's PASRR Interdisciplinary Team meeting. This failure placed residents at risk for inadequate care, and losing access to specialized mental health or intellectual disability services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident environment remains as free of accident hazards as is possible for 1 of 22 residents (Resident #14) reviewed for accidents and supervision. The facility failed to ensure Resident #14's fall mat was placed on the right side of her bed to help prevent injuries from falls. Resident #14 experienced an unwitnessed fall and was found sitting on the floor on the right side of her bed without the fall mat in place. These failures placed the residents at risk for fall-related injuries, hospitalization, and a decline in physical functioning.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews and record review the facility failed to ensure a resident receiving enteral feeding received appropriate treatment and services to prevent complications of enteral feeding for 1 out of 4 resident (Resident # 71) sampled for gastrostomy tube feeding quality of care. The facility failed to ensure Resident # 71 received ordered amount of tube feeding formula Jevity 1.5 CAL on 6/23/2026, 6/24/2026, and 6/25/2026 This failure could place residents with the use of the gastrostomy tubes at risk of inadequate intake of daily protein and calories.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 25 residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure MA A documented Resident #2's medication administration accurately in the facility's electronic medical record. MA A documented medications prior to administration to Resident #2 on 06/24/2026. This failure could place residents at risk of errors in care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 4 (Resident #2, Resident #3, Resident #4 and Resident #5) of 10 residents reviewed for Activities of Daily Living. The facility failed to provide Residents #2, Resident #3, Resident #4 and Resident #5 with adequate services to maintain personal hygiene that included incontinence care and periodic turning and repositioning. This failure could place residents at risk of diminished quality of life, decreased self-esteem or skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for 1 (Resident #1) of 10 residents reviewed for accidents and hazards. The facility failed to ensure that CNA A used a full body lift instead of a standing lift as instructed on Resident #1's care plan and had two staff members present when using a mechanical lift when transferring Resident #1 on 2/19/26. The failure could place residents at risk of possible injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for two (Resident #35 and Resident #1) of six residents reviewed for accidents and hazards. 1. The facility failed to ensure Resident #35 was free of accident hazards when CNA A used a mechanical standing lift (a medical device that assists individuals with limited mobility in transitioning from a seated to a standing position) while showering the resident, which resulted in the resident's foot slipping from the lift, falling to her knees, and sustaining compression fractures (a break in a vertebrae and then collapses to) the L1, L3, L4, and L5 vertebrae on 2/11/25. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for kitchen sanitation. Several food items in the refrigerator had use by dates that were expired but were still observed in refrigerator during initial kitchen observation. This failure could have the potential to affect residents who ate food from the facility's kitchen placing them at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 6 community bathrooms (shower #2) reviewed for physical environment in that: -Shower #2 on the second floor had mold on shower mattress and pillow. This failure could place residents at risk of infection leading to a diminished quality of life. Findings Included: Observation and interview on 02/13/2024 at 2:10 PM, LVN A accompanied surveyor to shower room [ROOM NUMBER] revealed shower #2 had a wedge pillow and the shower mattress covered with black and gray spots. LVN A said, That's mold. She said it was everyone's responsibility to keep the equipment clean. She said, housekeeping was in here earlier. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing of all drugs and biologicals to meet the needs of one resident (Resident #22) of four residents observed for medication pass. -Residents #22 was administered one tablet medications (Metoprolol ER [Extended Release]) that was crushed, even though crushing the medication was contraindicated. -The tablet of Metoprolol ER was crushed, which likely prevented the medication to be metabolized for its intended extended time release. -The MA combined 9 medications together by crushing 8 together and adding the contents of the capsule. The medications were than administered together to Resident #22. [...]