Shirley Chapman Sholom Home East

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure multi-dose medications were labeled upon opening and discarded in accordance with professional standards for 1 of 2 medications rooms reviewed and 1 of 5 medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, document review, the facility failed to ensure a proper sanitization technique was used to obtain food temperatures from ready-to-serve meals from the steam table. This finding had the potential to increase the risk of cross contamination and affect 17 residents who resided on the fourth floor.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure self-administration of medications was assessed and determined to be appropriate for 1 of 1 resident (R9) reviewed for self-administration of medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the use of as needed (i.e., PRN) psychotropic medication was limited to 14 days or extended to a certain date with supporting rationale provided by the medical provider for 1 of 5 residents (R8) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review, the facility failed to ensure that a discharge notice was sent to the Office of the State Long-Term Care Ombudsman (OOLTC) for 2 of 2 resident (R87, R89) reviewed for discharge.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure provider orders were followed to put on leg wraps for 1 of 1 resident (R6) reviewed for edema. In addition, the facility failed to ensure effective collaboration between the facility and the hospice agency for 1 of 1 resident (R8) reviewed who received hospice services.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure fall interventions were implemented for 1 of 3 residents (R90) who were at risk of falls.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure documentation of clinical indications for the continued use of a foley catheter was in place and failed to ensure interventions were in place to prevent urinary tract infections for 1 of 1 residents (R90) reviewed with a catheter.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff followed proper infection prevention and control practices by using the required personal protective equipment (PPE) during Enhanced Barrier Precautions (EBP) for 1 of 1 resident (R11) reviewed for infection control.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the plan of correction (POC) for the most recent survey of the facility was readily accessible and that the POC for the three preceding years was available upon request. This had the potential to affect all 82 residents residing in the facility as well as family, visitors, and staff. During observation and record review on 7/22/26 at 8:10 a.m., a review of the survey results binder located near the elevators on the first floor of the facility was completed. Although the binder included the survey results from the past three years, the 2024 and 2025 survey results did not include the facility's plan of correction (POC) or indicate that these could be requested from facility staff. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure dietary staff was wearing beard guards/restraints when preparing food. This had the potential to affect all 93 residents who reside at the facility and consume food from the kitchen. During observation on 4/16/25 at 10:03 p.m., cook (C)-A had a beard and was preparing roast beef and slicing it on the meat slicer. C-A was not wearing a beard guard/restraint. During observation on 4/16/25 at 10:11 a.m., the culinary manager (CM) had a beard and was stiring a large vat of beef stew. Then he started taking food temperatures and putting the food into an insulated food cart. The CM was not wearing a beard guard/restraint. During interview on 4/16/25 at 10:33 p.m., the CM verified the staff with beards were not wearing beard guards and it had never been an expectation for them to do so. [...]

Inspectors wroteBased on interview and document review, the facility failed to notify the provider of the use of antibiotics concurrent with warfarin, and to obtain a new INR monitoring date for 1 of 2 residents (R76) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a sanitary and homelike environment for 1 of 1 residents (R48) who had dried tube feeding formula on the base of the tube feeding pole.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 1 residents (R61) received treatments and services to promote the healing of a pressure ulcer per the comprehensive care plan.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a hand brace and palm protector was used consistently for 1 of 1 resident (R71) reviewed for range of motion (ROM).

Inspectors wroteBased on observation, interview, and document review, the facility failed to fully assess and follow up on weight loss and meal intakes for 1 of 2 resident (R73) reviewed for nutrition.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a feeding tube tubing and nutrition bag were labeled according to professional standards to avoid the possibility of feeding tube complications and or related infections for 1 of 1 residents (R48).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 resident (R23) reviewed for respiratory care.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure the recommended personal protective equipment (PPE) was utilized during high-contact cares for 2 of 3 residents (R48 and R53) reviewed for enhanced barrier precautions (EBP).

Inspectors wroteBased on interview and document review, the facility failed to review and revise the care plan with current interventions for the care of a new catheter and enhanced barrier precautions (EBP) for 1 of 1 residents (R2) reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 1 of 1 residents (R2) reviewed who had an indwelling catheter. In addition, the facility failed to ensure appropriate infection control measures for draining a catheter bag were implemented for 1 of 1 residents (R2) reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was properly stored, labeled, and dated. Additionally, the facility failed to ensure 2 of 2 dishwashers in the [NAME] and Macalester unit met minimum wash temperature. This had potential to affect all residents, staff, and visitors who eat food from the main kitchen and use dishes from the [NAME] and Macalester unit.

Inspectors wroteBased on interview, observation, and document review the facility failed to ensure the least restrictive infection control measures were implemented for 1 of 1 resident (R21) reviewed for covid-19 exposure. Additionally the facility failed to ensure hand hygiene was completed for 1 of 1 residents (R104) observed during contact precautions, failed to ensure standards of practice were followed for catheter care for 1 of 1 resident (R408) and failed to ensure proper storage of clean linen with the potential to impact 25 residents on two wings were implemented.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow resident to safely administer their own medication for 1 of 2 residents (R101) observed with medications at bedside.

Inspectors wroteBased on observation, interview, and document review, the facility failed to notify a provider for a significant weight gain for 1 of 1 resident (R104) reviewed for notification of change.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure grooming was offered and or provided for 2 of 3 residents (R16, R8) reviewed for shaving. The facility also failed to ensure nail care was provided for 1 of 1 resident (R8) reviewed for activitiy of daily living.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide assistance to ensure eyeglasses were available in order to maintain vision needs for 1 of 1 resident (R20) reviewed for vision.

Inspectors wroteBased on interview, and document review, the facility failed to ensure breakfast was provided to a resident prior to dialysis and failed to monitor food intakes for 1 of 3 residents (R20) reviewed for nutrition.