United Hebrew Geriatric Center

Inspectors wroteBased on record reviews, interviews, and observations conducted during an abbreviated (2968858) survey, the facility did not ensure that a resident was free from abuse. This was evident for 1 (Resident #1) of 3 residents sampled for abuse. Specifically, Certified Nursing Assistant #1 is seen in video footage dated 03/26/2026 hitting the back of Resident #1's head. The facility policy #276 for abuse prevention last reviewed January 2025 documented that it was their policy to ensure all residents were free from abuse, neglect, misappropriation of resident property and exploitation. Resident #1 was admitted [DATE] with diagnoses which included unspecified dementia, unspecified severity, with other behavioral disturbance. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (2968858), the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and law enforcement) in accordance with State law through established procedures. This was evident in one out of three residents reviewed for abuse (Resident #1). [...]

Inspectors wroteBased on record review, and interviews during an abbreviated survey (2968858), the facility did not ensure a comprehensive care plan was developed and implemented to maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) residents reviewed for abuse. Specifically, Resident #1 had severe cognitive impairment and was involved in a documented incident on 03/26/2026 where abuse occurred and an abuse care plan was not initiated. Review of the facility policy #2-214 comprehensive person-centered care plan dated 1/2023 documented that a comprehensive person-centered care plan is developed for each resident to include measurable goals, objectives and timeframe to meet the resident's medical, nursing, rehabilitation, psycho-social, cultural and nutritional needs. [...]

Inspectors wroteBased on record review and interview the facility did not ensure a Notice of Medicare Non-Coverage is given by the facility to all Medicare beneficiaries at least two days before the termination of services for one (1) of three (3) residents (Resident #194) reviewed for Beneficiary Notification. Specifically, there was no documented evidence that Resident #194 and/or their representative received and signed a two (2) day Notice of Medicare Non-Coverage before termination of services.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that drugs and biologicals were maintained in accordance with current professional standards for storage, labeling and expiration dates during review of medication storage on two (2) of four (4) units. Specifically, 1) observation of the fourth-floor medication cart revealed one (1) insulin pen with no open date and one (1) insulin pen with no patient label and no open date. The fifth-floor medication cart revealed two (2) insulin pens which had not been discarded within 28 days after opening as per the manufacture's recommendation, and 2) a physician ordered Trelegy Ellipta (inhaler) was left in Resident #155's room on the bedside table.

Inspectors wroteBased on observation, interview, and record review during the recertification survey from 10/2/23 to 10/6/23, the facility did not ensure that care was provided in a manner that maintained dignity for 1 of 2 residents (Resident #7) reviewed for catheters. Specifically, Resident #7 urinary catheter drainage bag was not concealed to prevent direct observation of urine by others.

Inspectors wroteBased on interview, and record review during the recertification survey from 10/2/23 to 10/6/23, it was determined the facility did not ensure an ongoing program of activities was provided to meet the needs and interests of, and support the physical, mental, and psychosocial well-being of the residents, based on the comprehensive assessment and care plan for 1 of 2 residents (Resident #18) reviewed for activities. Specifically, Resident #18 voiced concern about the facility's cuts to their activities programming and how it negatively affected their daily quality of life.

Inspectors wroteBased on observations, interviews and record review during a recertification survey from 10/2/23 to 10/6/23, the facility did not ensure food was served under sanitary conditions for 2 of 12 residents (Residents #335 and #126) . Specifically, registered nurse (RN) #1 did not perform hand hygiene between serving residents while passing out food during a breakfast meal to prevent cross contamination and infection and was wearing gloves to serve meals.

Inspectors wroteBased on observation, record review and interview during the recertification survey (10/2/23-10/6/23) the facility did not ensure that staff maintained 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. Specifically, two Certified Nurse Aides (CNAs) were observed not using Personal Protective Equipment (PPE) while assisting a resident that was on contact precautions and when CNAs exited the resident room, did not perform proper hand hygiene.

Inspectors wroteBased on record review and interview conducted during a recertification survey, the facility did not ensure that for 1 of 2 residents (#180) reviewed for hospitalization that the resident or her representative were given timely written notification of the bed hold policy before transfer in a language and manner they could understand.

Inspectors wroteBased upon interview and record review conducted during the recertification survey, the facility did not ensure that each resident received proper treatment and assistive devices to maintain hearing ability. This was evident for 1 of 38 residents reviewed. (Residents#109).