Every finding on record at Jewish Healthcare Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included to administer an anti-anxiety medication three times per day, the facility failed to ensure professional standards of practice were maintained when nursing changed the order for the medication to be administered only twice a day, without consulting a physician, in accordance with nursing best practice and facility policy.Findings include:Review of the facility's policy, titled Medication Reconciliation, with a review date of 6/06/25 indicated the following:-It is the policy of the [facility] to accurately and completely reconcile medications across the continuum of care. The process of medication reconciliation involves comparing a patient's/resident's medication orders to all the medications that the patient has been taking to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. On admission all medications taken by the resident prior to admission (prior setting and home) will be reviewed with current orders and reconciled.-On admission, a licensed nurse will review and compare the discharge medication list from the prior setting to the facility admission orders. Any changes, variations, and/or discrepancies identified will be clarified.-On all new admissions, the nurse will review the current medication orders with the patient/resident or family member/responsible person and obtain a history of medications taken at home.-A second licensed nurse will perform a medication reconciliation, comparing both the discharge summary with the orders that have been entered into the electronic health record to ensure no errors have been made.-The admission medication reconciliation process will ensure there are no medications taken at home that were unintentionally omitted and that the patient and/or responsible party have knowledge of the reconciliation process.Resident #1 was admitted to the facility in January 2026, diagnoses included anxiety disorder and Down Syndrome.Resident #1's Hospital Discharge summary, dated [DATE], included a medication order listed under modified medication which included the following:-Clonazepam 1 milligram (mg) tablet, take one tablet by mouth twice daily.Further review of the Summary indicated Resident #1 had been prescribed and administered Clonazepam 1 mg by mouth three times daily during his/her hospitalization, until the morning dose on 01/23/26 when the medication frequency was modified.During an interview on 04/07/26 at 3:23 P.M., Nurse Practitioner (NP) #1 said that the day Resident #1 was admitted to the facility, a nurse came to her and said that Resident #1's family member said Resident #1 had been taking Clonazepam 1 mg three times per day since before, and during, his/her hospitalization. NP #1 said she wrote Resident #1's prescription order for Clonazepam 1 mg three times a day.Review of Resident #1's Medication Administration Record (MAR) for the month of January 2026, indicated that he/she had a physician's order, dated 01/23/26, for Clonazepam was for 1 mg by mouth three times daily. During a telephone interview on 04/03/26 at 10:28 A.M., Family Member #1 said she had visited Resident #1 at the facility on 01/26/26 and 01/27/26 and he/she was more angry. Family Member #1 said Resident #1 presented that way when he/she did not take the prescribed Clonazepam. Family Member #1 said she voiced her concerns to the nursing staff and was told Resident #1 had only been receiving Clonazepam 1 mg by mouth only twice a day.Further review of the MAR indicated Resident #1's order for Clonazepam had been changed on 01/24/26 by nursing, to be administered only twice a day.The MAR indicated Resident #1 was administered Clonazepam 1 mg by mouth twice a day from 01/24/26 through 01/26/26.During a telephone interview on 04/08/26 at 7:30 A.M., Nurse #1 said that part of her duty was to double-check the reconciliation of medications. Nurse #1 said when she reconciled Resident #1's admission medications, she noticed that his/her Hospital Discharge Summary indicated he/she had an order for Clonazepam 1 mg twice daily, and the order that had been entered into the facility's Electronic Medical Record (EMR) was for Clonazepam 1 mg three times a day.Nurse #1 said she thought nursing had entered the Clonazepam order in error and changed it back to be given twice daily, without consulting a practitioner.Nurse Practitioner #1 said she was very upset when she found out nursing had changed the frequency of Resident #1's Clonazepam order without consulting her or the Physician. NP #1 said Resident #1 should have been given Clonazepam 1 mg three times a day during his/her stay at the facility. Review of the Facility's Medication/Treatment Incident Report, dated 01/27/26, indicated Resident #1's order for Clonazepam was changed by nursing, from three times a day to twice a day, without calling a practitioner for clarification.During an interview on 04/07/26 at 3:50 P.M., the Director of Nurses (DON) said she signed off on Resident #1's Medication/Treatment Incident Report on 01/29/26 and said the investigation concluded that there was a breakdown in communication regarding Resident #1's Clonazepam order, which resulted in the error.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the facility failed to ensure they maintained a complete and accurate medical record related to meal percentage intakes for five out of 14 applicable meals.Findings include:Resident #1 was admitted to the facility in January 2026, diagnosis included status post small bowel resection.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she had received total parenteral nutrition (TPN- all essential nutrients are delivered intravenously) during his/her hospitalization due to significant malnutrition. The Summary indicated his/her TPN was discontinued on 01/20/26.Review of Resident #1's Certified Nurse Aide (CNA) Flow Sheets, for the month of January 2026, indicated that under the box to record his/her meal intake percentage, the following days/meals were left blank:-01/25/26- dinner-01/26/26- breakfast-01/26/26- lunch -01/27/26- breakfast-01/27/26- lunch The Facility was unable to provide the surveyor with Resident #1's Certified Nurse Aide assignments during his/her stay at the facility.During an interview on 04/07/26 at 1:03 P.M., Certified Nurse Aide (CNA) #1 said the CNAs are responsible to document meal percentage intakes for each resident at each meal.During an interview on 04/07/26 at 1:35 P.M., Unit Manager #1 said documenting the residents' meal intake percentage at each meal was part of the CNAs routine documentation.During an interview on 04/07/26 at 3:50 P.M., the Director of Nurses (DON) said they do not have a policy related to medical record accuracy and documentation because it was a standard of care. The DON said the CNAs were expected to document all of Resident #1's meal intake percentages.

Based on interviews and records reviewed, the facility failed to ensure that one Resident (#110) out of a total sample of 26 residents was provided the right to participate in the care plan process.Specifically, the facility failed to ensure that Resident #110 was provided the opportunity to participate in his/her initial and quarterly care plan meetings and also failed to document in the medical record why the Resident could not or did not participate in the two care plan meetings. Findings include:Review of the facility Patient/Resident admission Agreement and Information Packet, last revised 1/1/19 indicated: -the Center will develop a Plan of Care which describes in writing the medical, nursing and psychosocial needs of the Patient/Resident and how such needs will be met, so that the Patient/Resident will attain or maintain his or her highest practical physical, mental and psychosocial well-being. -This Plan will be prepared with the participation, to the extent practical, of the Patient/Resident, Patient's/Resident's family, Responsible Party or Legal Representative, and the Center's Team. Review of the facility policy titles Family and Interdisciplinary Team Meetings, last revised 12/10/25, indicated:-It is the policy of the facility to hold interdisciplinary team meetings with the resident, responsible party, or next of kin and interdisciplinary team to include but not limited to nursing, recreational therapy, social service, rehab service and clinical practitioner.-Team meetings will be scheduled after admission, quarterly thereafter as needed for any change in resident condition or discharge disposition.-Social Service department is responsible for scheduling meetings and contacting family/responsible party based on resident's preference. -All disciplines attending will report Resident's status, any changes in condition, and all care plans will be reviewed with all attendees.>Care plans will be individualized based on the information provided by the interdisciplinary team as well as residents and family. Resident #110 was admitted to the facility in September 2025, with diagnoses including anxiety, muscle weakness, and Dementia. Review of the MDS (Minimum Data Set) assessment dated [DATE], indicated that Resident #110:-was cognitively impaired as evidenced by a Brief Interview of Mental Status (BIMS) score of 4 out of 15. -was English speaking.-makes himself/herself understood and usually understands others. During an interview on 1/15/26 at 9:05 A.M., Resident #110 said that he/she was unaware of what a care plan meeting was. During an interview on 1/20/26 at 7:58 A.M., Resident #110 said that he/she had never been invited to a care plan meeting, but that he/she would definitely like to go to one. Review of Resident #110's clinical record failed to indicate any evidence that the Resident participated in the care planning process with the interdisciplinary team (IDT) during the Resident's care plan meeting reviews held on 10/30/25 and 1/2/26. Further review of the clinical record failed to indicate the rationale as to why the Resident did not or could not participate in any care plan meetings, or refusals to participate in the meetings on 10/30/25 and 1/2/26. During an interview on 1/20/26 at 8:55 A.M., Unit Manager (UM) #2 said that the facility invites residents to care plan meetings, unless they have determined that it would be detrimental to invite them and cause the residents' emotional upset. During an interview on 1/21/26 at 8:44 A.M., the Social Worker (SW) said that all residents should be invited to their care plan meetings, that Resident #110's Healthcare Proxy (HCP) had been invited to attend Resident #110's care plan meeting and that Resident #110 was not invited to attend either meeting because his/her HCP had been invoked. The SW also said that she did not have documented evidence in the Resident's record as to why the Resident had not been invited to attend either of his/her care plan meetings, as required. During an interview on 1/21/26 at 9:07 A.M., the Director of Nursing (DON) and Clinical Services said that being invited to care plans meetings is a resident's right.

Based on observation, record review and interview, the facility failed to provide respiratory care and services consistent with professional standards of practice relative to the care and maintenance of oxygen equipment for one Resident (#84) out of a total sample of 26 residents.Specifically, for Resident #84, the facility failed to ensure that an oxygen concentrator filter was maintained in a clean and sanitary manner. Resident #84 was admitted to the facility in October 2024 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #84 was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of a total possible score of 15. On 1/15/26 at 10:24 A.M., the surveyor observed Resident #84 seated in a wheelchair next to his/her bed with a nasal cannula in his/her nose and the oxygen tubing connected to an oxygen concentrator. The oxygen concentrator was observed to be running and set to deliver 1.5 liters per minute (LPM) of oxygen to the Resident. The surveyor also observed that the filter located on the left side of the oxygen concentrator was covered entirely with thick grey dust. Review of Resident #84's January 2026 Physician's orders included:-Humidified Oxygen:1 - 4 liters per minute, may titrate to keep sats (oxygen saturation) greater than 90% every shift for SOB (shortness of breath). Review of the Resident's Medical Record failed to include any indication that staff cleaned the filter located on the left side of the oxygen concentrator. Review of the facility policy titled Oxygen Maintenance, last revised 10/15/25, indicated:-The Center shall maintain all oxygen concentrators in a clean, safe and functional condition.-Weekly cleaning of oxygen concentrator filters and weekly oxygen tubing changes are mandatory. Review of the Resident's medical record failed to provide any evidence that staff had cleaned the filter on the oxygen concentrator. On 1/20/26 at 1:18 P.M., the surveyor and Unit Manager (UM) #1 observed that Resident #84 was receiving oxygen therapy and the filter on the oxygen concentrator remained covered entirely with thick grey dust. During an interview at the time, UM #1 said that the filter was covered with dust and that it should not have been covered in dust. UM #1 said that she was not sure who was responsible for cleaning and maintaining the filter on the oxygen concentrator but that she would find out. During an interview on 1/21/26 at 8:02 A.M., the Director of Clinical Services said that she had been made aware of the issue with Resident #84's oxygen concentrator filter and that UM #1 had told her that the filter was dirty. The Director of Clinical Services said the 11:00 P.M. - 7:00 A.M. (night shift) staff were responsible for cleaning the filters on the oxygen concentrators. The Director of Clinical Services said the filters on the oxygen concentrators should be cleaned every Wednesday.

Based on observation, record review, and interview, the facility failed to ensure that the medication error rate was not five percent (5%) or greater when one Nurse (#1) out of three Nurses observed during the medication pass procedure, made two errors in 26 total opportunities, for a medication error rate of 7.69%, impacting one Resident (#119) of six residents observed, out of a total sample of 26 residents. Specifically, for Resident #119, the facility failed to: ensure that Nurse #1 followed the Physician orders for Losartan Potassium (blood pressure medication used to treat hypertension) to be held when Resident #119's systolic blood pressure (the top/upper number for blood pressure measurement) reading was less than 130 mmHg (millimeters of mercury). ensure that Nurse #1 administered the correct Calcium medication when Calcium/ Vitamin D 600 mg (milligrams) /10 mcg (micrograms) was administered to Resident #119 and Calcium 1200 mg was ordered by the Physician.Findings include: Review of the facility policy titled Physician Orders, revised 9/5/25, included but not limited to:The facility shall ensure that all resident care, treatment, medications, and services are provided only upon valid physician or authorized practitioner orders. Orders must be clear, complete, properly documented, promptly carried out, and authenticated. >Orders are carried out promptly and safely.Resident #119 was admitted to the facility in November 2021, with diagnoses including Cardiomegaly Nonrheumatic Mitral (Valve) Insufficiency, Chronic Kidney Disease Stage 2, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Multiple Sclerosis and age-related Osteoporosis. Review of Resident #119's Physician orders dated 1/16/26, indicated the following:-Losartan Potassium Oral Tablet 100 mg (Losartan Potassium). Give 1 tablet by mouth one time a day related to Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 through Stage 4 chronic kidney disease, or unspecified chronic disease. Hold for SBP (systolic blood pressure) less than 130, initiated 4/4/23, discontinued 1/16/26.-Calcium 600 Oral Tablet. Give 1200 milligrams (mg) by mouth, one time a day for Calcium supplement, initiated 12/24/25. On 1/16/26 at 9:00 A.M., during medication administration, the surveyor observed Nurse #1 assess Resident #119's blood pressure and administer the following medication:-Losartan Potassium Oral Tablet 100 mg one tablet by mouth. -Calcium/Vitamin D 600 mg/ 10 micrograms (mcg) two tablets by mouth.-Blood pressure reading of BP 113/65 mmHg was obtained. Review of Resident #119's January 2026 Medication Administration Record (MAR), indicated Nurse #1 had electronically signed that the following medications were administered on 1/16/26:-Losartan Potassium Oral Tablet 100 mg with the Resident's SBP documented as 113 mmHg. -Calcium Oral Tablet (Calcium) 1200 mg. Further review of Resident #119's January 2026 MAR indicated 100 mg Losartan Potassium Oral Tablet was electronically signed by Nursing staff as administered when the SBP was less than 130 on the following dates:-1/3/26: SBP reading of 128 mmHg-1/14/26: SBP reading of 123 mmHg Review of Resident #119's December 2025 MAR, indicated 100 mg Losartan Potassium Oral Tablet was electronically signed by Nursing staff as administered when the SBP was less than 130 on the following dates:-12/6/25: SBP reading of 125 mmHg-12/29/25: SBP reading of 122 mmHg During an interview on 1/16/26 at 11:57 A.M., the surveyor and Nurse #1 reviewed the Physician orders for Resident #119 and Nurse #1 said that the Physician orders indicated to hold Resident #119's Losartan Potassium when the SBP was less than 130 mmHg and he administered the medication when Resident #119's SBP was 113 mmHg. Nurse #1 also said that the Physician orders indicated to administer Calcium Carbonate 1200 mg, and he administered Calcium/ Vitamin D 600 mg/10 mcg. Nurse #1 said that he did not see the Physician orders indicating to hold the Losartan Potassium when the blood pressure was less than 130 mmHg. Nurse #1 further said that he should not have administered the 100 mg Losartan Potassium and the Calcium/ Vitamin D 600 mg/10 mcg medication to Resident #119, but he did. During an interview on 1/16/26 at 1:47 P.M., the Director of Nursing (DON) said that Nurse #1 should not have administered the 100 mg Losartan Potassium and Calcium/ Vitamin D 600 mg/10 mcg to Resident #119. The DON also said that Nurse #1 should follow the Physician orders to hold and not administer the blood pressure medication.

Based on observation, interview and record review, the facility failed to ensure that medication was stored in a safe and sanitary manner in the medication carts on one (Fifth-Floor North) out of four medication carts reviewed.Specifically, the facility failed to ensure that Nurse #2 stored medications in a safe and sanitary manner in the Fifth-Floor North medication cart when Nurse #2 was observed storing one pre-poured medication cup containing resident medications in the top drawer and a second medication cup containing pre-poured resident medications in the bottom drawer of the medication cart. Findings include:Review of the facility policy titled, Oral Medication Administration Procedure, revised 1/1/25, included but not limited to:It is the policy of the facility to administer resident medications in an organized and safe manner.>Meds are never pre-poured. Review of the facility policy titled, Medication Storage, revised 10/16/25, included but not limited to:It is the policy of the facility that all medications within the facility shall be stored, labeled, secured, and monitored in a manner that:>Maintains drug integrity and potency. On 1/16/26 at 10:24 A.M., the surveyor observed the following pertaining to Nurse #2 and the Fifth-Floor North medication cart:-Nurse #2 opened the medication cart and picked up an item from the bottom drawer of the medication cart and held the item behind her back. -When the surveyor asked Nurse #2 what she was holding behind her back, Nurse #2 showed the surveyor a medication cup with no name or label present, containing apple sauce mixed with white tablets and a blue and white capsule.-Nurse #2 then opened the top drawer of the medication cart and the surveyor observed an unlabeled plastic medication cup containing three white tablets and one white capsule. During an interview at the time, Nurse #2 said when she went to administer the medications to a resident, but the resident had refused the medications. Nurse #2 said she should have immediately destroyed the medications that were mixed in apple sauce when the resident refused the medications. Nurse #2 also said that she had placed the second medication cup containing medications for another resident in the bottom drawer because that resident had refused the medications earlier. During an interview on 1/16/26 at 1:45 P.M., the Director of Nursing (DON) said that the standard practice for nursing staff was to destroy medications immediately that were refused by residents. The DON also said that the medications should have been destroyed by Nurse #2.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for food safety relative to the use and preparation of unpasteurized eggs to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility staff failed to utilize pasteurized eggs for the preparation of over easy (eggs fried on both sides with a runny yolk) eggs to safely accommodate resident's choices during the breakfast meals and ensure that the unpasteurized eggs being used were appropriately cooked until all parts of the egg were completely firm placing the residents who were served the over easy, unpasteurized eggs at risk for foodborne illness. Findings include:Review of the facility's policy titled Enhanced Dining, last revised 4/24, included but not limited to:-Fried eggs prepared to order must be cooked over hard (eggs cooked until both the whites and the yolk are completely solid and firm, with no runny liquid left) due to the fact that we do not use pasteurized whole eggs. -No eggs over easy or sunny side up (fried egg that is cooked on only one side, resulting in a fully set white and a bright, runny yolk that resembles the sun). Review of the facility invoices from the facility vendor dated 10/6/25, 10/13/25, 10/16/25, 10/20/26, 11/6/25, 11/10/25, 11/20/25, 12/1/25, 12/4/25, 12/11/25, 12/18/25 and 12/29/25, indicated that the whole eggs purchased to make the over easy eggs in the facility were unpasteurized. On 1/16/26 at 8:16 A.M., the surveyor observed a staff member in the third-floor dining room serve breakfast to one resident which included one egg cooked over easy. The resident was observed to cut the over easy egg with his/her fork and then eat the over easy egg with runny yolk. On 1/20/26 at 8:05 A.M. through 8:17 A.M., the surveyor observed the breakfast meal in the third-floor dining room. The surveyor observed that two residents were eating over easy eggs with running yoks. During an interview on 1/20/26 at 8:25 A.M., Dietary Staff #1 who was the facility cook said that the Food Service Director (FSD) orders pasteurized eggs and she could make over easy eggs for the residents. Dietary Staff #1 said she had prepared over easy eggs with runny yolks and served to residents on 1/16/26 and 1/20/26, and the eggs were not pasteurized. During an interview on 1/20/26 at 8:34 A.M., Dietary Staff #1 said that the facility does not purchase pasteurized whole eggs. Dietary Staff #1 said that the whole eggs she used for the over easy eggs for breakfast were not pasteurized. During an interview on 1/20/26 at 9:05 A.M., the FSD said that he was responsible for ordering food for the facility including eggs. The FSD said that the whole eggs purchased were not pasteurized. The FSD said that the whole eggs used by Dietary Staff #1 for the over easy eggs at breakfast were not pasteurized. The FSD said that the eggs should not have runny yolks and should have been cooked through to prevent foodborne illness for the residents.

Based on record and policy review, and interview, the facility failed to ensure a Preadmission Screening and Resident Review Level I (PASRR-screening that assesses for Serious Mental Illness or Developmental Disabilities [Level I screen (initial pre-screening completed prior to admission to a Nursing Facility]) was completed prior to admission for one Resident (#107) out of a total sample of 26 residents. Specifically, for Resident #107, the facility failed to ensure that a Level I screen was completed prior to the Resident's admission to the facility to assist in determining the level of services needed. Findings include: Review of the facility policy titled PASRR Screening for Admission/Readmission, last revised 7/29/24, indicated: -that prior to admission, the facility will complete a Level I PASRR to evaluate for the presence of a mental disorder or intellectual disability. Resident #107 was admitted to the facility in July 2024, with diagnoses including Post Traumatic Stress Disorder (PTSD- a mental health condition that is caused by an extremely stressful or terrifying event - either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event). Review of Resident #107's medical record failed to indicate a Level I PASRR had been completed prior to admission to the facility. Further review of the medical record indicated that the Level I had been completed on 8/15/24, after the Resident's admission to the facility. During an interview on 10/8/24 at 3:46 P.M., the Director of Nursing (DON) said that Resident #107's Level I PASRR had been completed late and should have been completed prior to the Resident's admission to the facility.

Based on observation, interview, record and policy review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections within the facility on one Unit (Fourth Floor) out of three total Units. Specifically, the facility failed to: 1) clean and disinfect a glucometer (device used to test sugar level in the blood) after resident use to prevent potential contamination and potential transmission of blood-borne disease. 2) ensure wound care supplies brought into a resident room were designated for use on that resident and stored in that resident's room to prevent potential cross-contamination. Findings include: 1) Review of the facility policy titled Glucometer Cleaning, revised 5/2/24, indicated the following: -Blood glucose meters (glucometer) . must be cleaned and disinfected after each patient/resident use. -Per OSHA [Occupational Safety and Health Administration] and manufacturer's guidelines, and EPA [Environmental Protection Agency] approved disinfectant, effective against HBV (Hepatitis B Virus-a virus that can cause infection of and damage to the liver), HCV (Hepatitis C Virus- a virus that can cause infection of and damage to the liver, and HIV (Human Immunodeficiency Virus-a virus that can cause weakening of the bodies ability to fight infection and illness) is used on glucometers. PDI wipes (a specific brand of disinfectant wipes) meet this requirement. On 10/8/24 at 3:45 P.M., during a medication pass process on the Fourth Floor Unit, the surveyor observed Nurse #1 take a cloth glucometer storage bag containing a glucometer, lancets (device used to pierce skin to obtain blood sample for glucometer), alcohol prep pads (used to clean/disinfect the finger used for before lancet), and test strips (inserted to glucometer to obtain blood) and bring the items into a resident room. Nurse #1 was observed to set the storage bag on the resident's bed next to the resident. The surveyor then observed Nurse #1 take supplies out of the bag, perform the blood test, and then return the glucometer to the storage bag, zip the bag and return it to the medication cart. The surveyor did not observe Nurse #1 disinfect the glucometer before placing it into the storage bag. During an interview immediately following the observation, Nurse #1 said the glucometer was used for all residents on her assignment. Nurse #1 further said she should not have placed the cloth storage bag on the bed or placed the glucometer back into the bag without cleaning and disinfecting the glucometer with PDI wipes due to the risk for cross-contamination. During an interview on 10/9/24 at 12:41 P.M., the surveyor reviewed Nurse #1's observation with the Infection Control Preventionist (ICP). The ICP said the expectation would be that Nurse #1 should not have brought the cloth storage bag into the resident room or set it on the resident's bed to prevent cross-contamination. The ICP also said that Nurse #1 should have cleaned and disinfected the glucometer per facility policy before placing the glucometer back into the storage bag to prevent cross-contamination. 2) Review of the facility policy titled Wound Care: Assessment and Documentation of Wounds, revised 7/1/24, indicated the following: -any leftover supplies that have been brought into the room, should be labeled with open date and left in [the] room, -do not place [supplies] back into treatment cart. On 10/9/24 at 10:08 A.M., during a wound care observation on the Fourth Floor Unit, the surveyor observed the Staff Development Coordinator (SDC)/Wound Nurse use a bottle of wound cleanser (a solution used to clean wounds) and then place the bottle of wound cleanser on the resident's bed. After completion of the wound care, the surveyor observed the SDC/Wound Nurse take the bottle of wound cleanser and place it into the treatment cart. During an interview immediately following the observation, the SDC/Wound Nurse said she should not have placed the bottle of wound cleanser on the resident's bed and then return it to the treatment cart due to concern for cross-contamination. During an interview on 10/9/24 at 12:38 P.M., the ICP said the expectation was that the SDC/Wound Nurse would not place a shared wound care supply onto the resident's bed. The ICP further said, if the wound care supply was placed in the resident's room and/or bed, that it should have been labeled and left in the resident's room per facility policy to prevent cross-contamination.

Based on record review, interviews, and observations, the facility failed to assess, manage, and effectively treat one Resident (#394) out of a total sample of 26 residents for pain. Specifically, the facility staff failed to assess Resident #394 in a timely manner for pain, provide pain medication as needed upon the Resident's request, and re-assess for the effectiveness of the Resident's pain medication, which prevented the Resident from participating in his/her scheduled Physical Therapy session. Findings include: Resident #394 was admitted to the facility in July 2023 with diagnoses including Idiopathic Scoliosis (abnormal curve of the spine with no definitive cause), status post [NAME] Revision (a procedure that immobilize the base of the spine, with screws, rods, or other instruments to hold the spine stable while the bones grow together), Orthopedic after care. Review of the facility's policy titled Pain Management, revised 7/31/22, included: -It is the policy of the Jewish Healthcare Center to take an aggressive approach to pain management. Goals of an effective pain management program include prompt assessment, diagnosis, and treatment of pain. -The Jewish Healthcare Center believes and supports the patient's/resident's right to live as pain free as possible. All patients and residents have a right to pain relief. All healthcare providers of the Jewish Healthcare Center will make every reasonable and prudent effort to provide maximum comfort to our patients and residents. -To provide effective and high-quality pain management to patients/residents of the Jewish Healthcare Center. -To optimize the patient's/resident's ability to perform ADLs (activities of daily living), Rehab, and participate in activities. -Patients and residents will be encouraged to report effectiveness and/or ineffectiveness in which case the patient/resident may request further medication to improve consistent management. Review of the Minimum Data Set (MDS) assessment, dated 7/9/23, indicated Resident #394 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of a total 15 possible points. Review of Resident #394's July 2023 Physician's orders indicated: -Oxycodone 10 milligrams (mg) tablet, give 10 mg by mouth every four hours as needed (PRN) for pain -Oxycodone 10 mg tablet, give 10 mg by mouth one time a day for pain, at 0000 (midnight). Review of Resident #394's Pain Care Plan, initiated 7/7/23, included: - The Resident is at risk for pain related to Idiopathic Scoliosis, status post [NAME] Revision. - The Resident will not have interruption to normal activities due to pain through the review date (target date 7/25/23). - Anticipate the Resident's need for pain relief and respond immediately to any complaint of pain. - Evaluate the effectiveness of pain interventions, alleviating of symptoms, dosing schedules, resident satisfaction with results, impact on functional ability and impact on cognition. During an interview on 7/18/23 at 10:20 A.M., Resident #394 said it took staff 45 minutes that morning to provide him/her PRN pain medication when he/she requested the PRN medication for pain in his/her back. The Resident said he/she was still waiting for the PRN medication to work. During an interview on 7/19/23 at 3:07 P.M., Resident #394 said he/she had to wait for two hours to receive PRN pain medication that morning. The Resident said that he/she requested PRN pain medication at 7:15 A.M., and again at 8:00 A.M., but did not receive the PRN pain medication until 9:15 A.M. The Resident said he/she was unable to participate in Physical Therapy when the Therapist arrived at 9:15 A.M. because he/she was in so much pain. Review of the Resident's July 2023 Medication Administration Record (MAR) included the following: -PRN Oxycodone 10 mg by mouth was administered at 6:28 P.M. on 7/18/23. -PRN Oxycodone 10 mg by mouth was administered at 9:21 A.M. on 7/19/23. Review of the Nursing Progress Note dated 7/19/23 at 11:47 A.M., indicated the PRN medication (Oxycodone) was ineffective. During an interview on 7/19/23 at 3:28 P.M., Physical Therapist #1 said that Resident #394 was unable to participate in therapy that morning at 9:15 A.M., due to reported pain of 10 on a scale of 10. During an interview on 7/19/23 at 3:30 P.M., Nurse #4 said that staff had reported to her at 7:15 A.M. the Resident was in pain at a level of 8 out of 10. Nurse #4 said that she did not see the Resident until 8:00 A.M., and the Resident continued to report pain, but she did not administer the PRN medication at that time. Nurse #4 said that she did not provide the PRN pain medication to the Resident until 9:15 A.M., after the Physical Therapist informed her that the Resident had reported pain at 10 out of 10, and could not participate in his/her scheduled physical therapy session. During an interview on 7/20/23 at 8:30 A.M., the Director of Nursing (DON) said that she expected her staff to provide PRN pain medication within 15 to 25 minutes after a resident requested PRN pain medication. During a follow-up interview on 7/21/23 at 8:35 A.M., the DON said that when Nurse #4 was notified of Resident #394's report of pain, the Nurse should have assessed the Resident's pain and administered the PRN pain medication as ordered and as requested by the Resident. The DON further said that Nurse #4 should have returned to assess the effectiveness of the medication, as required, but she did not.

Based on observations, policy review, and interviews, the facility failed to provide a dignified dining experience for one Resident (#14) out of a total sample of 26 residents. Specifically, staff stood over the Resident while feeding meals, rather than sitting at eye level. Findings include: Review of the facility policy for Feeding Assistance, last revised 12/14/22, indicated that staff assisting residents will sit in close proximity to those they are helping and engage the resident in the mealtime task. Resident #14 was admitted to the facility in August 2012 with diagnoses including Dementia (a group of symptoms that effects memory, thinking and interferes with daily life) and malnutrition. Review of the Minimum Data Set (MDS) assessment, dated 4/19/23, indicated that Resident #14 was assessed by staff to have a severe cognitive impairment and was rarely/never understood. Further review of the MDS indicated that the Resident was totally dependent for feeding tasks. On 7/18/23 at 9:48 A.M., the surveyor observed Nurse #1 feeding Resident #14 breakfast. The Nurse was standing over Resident #14 while feeding him/her breakfast and was not at eye level with the Resident. On 7/19/23 at 9:31 A.M., the surveyor observed Nurse #1 feeding Resident #14 breakfast. The Nurse was standing over Resident #14 while feeding him/her breakfast and was not at eye level with the Resident. During an interview on 7/19/23 at 9:33 A.M., Nurse #1 said that she had been standing over Resident #14 while feeding him/her. During an interview on 7/19/23 at 9:52 A.M., the Director of Nurses (DON) said that the staff member should have been sitting down while feeding the Resident and not standing.

Based on interview and record review, the facility failed to refer two Residents (#81 and #110) out of three applicable residents, in a total sample of 26 residents for a Level II evaluation (an in-depth evaluation of a person who has a positive Level I screen for Mental Illness (MI), intellectual disability, or related condition in order to determine if they require specialized services) Preadmission Screening and Resident Review (PASRR). Specifically, the facility staff failed to refer both Residents for a Level II evaluation for: 1. Resident #81 who was identified post admission to have a diagnosis of MI and had limitations in major life activities due to MI within the last six months of his/her admission to the facility. 2. Resident #110 who required an inpatient Psychiatric hospitalization . Findings include: 1. Resident #81 was admitted to the facility in June 2020. Review of Resident #81's Level 1 Preadmission Screening and Resident Review (PASRR- an evaluation to determine if a Resident has MI or Intellectual or Developmental Disability (ID/DD) and needs an additional Level II evaluation), dated 6/5/20, indicated that Resident #81 did not have a diagnosis of MI. Review of the Physician's Progress Note, dated 2/8/23, indicated that Resident #81 had a diagnosis of Paranoid Schizophrenia present on admission to the facility. Further review of the Physician's Progress Note, dated 4/3/23, revealed that the Resident had been hospitalized prior to his/her admission to the facility due to a diagnosis of failure to thrive (FTT- a decline seen in older adults - typically those with multiple chronic medical conditions - resulting in a downward spiral of poor nutrition, weight loss, inactivity, depression and decreasing functional ability) after the death of his/her mother. Further review of the clinical record did not indicate that the Level I evaluation had been updated and resubmitted as required, after it had been identified that the Resident had a diagnosis of MI and had limitations in major life activities present on admission. During an interview on 7/20/23 at 1:01 P.M., Social Worker #2 said that the facility Social Workers should have updated and submitted the Level I evaluation to the Department of Mental Health (DMH) PASRR office once it had been determined that the Resident had a pre-existing mental health diagnosis as required, and it had not been. 2. Resident #110 was admitted to the facility in April 2023. Review of the clinical record indicated that Resident #110 had been transferred to a Psychiatric hospital on 6/16/23 for behaviors. Further review of the clinical record did not indicate that the Level I evaluation had been updated and resubmitted as required, after it had been identified that the Resident had been admitted for an inpatient Psychiatric hospitalization . During an interview on 7/20/23 at 1:01 P.M., Social Worker #2 said that a Level II PASRR evaluation should have been obtained by the facility Social Workers from the DMH PASSR office after the resident's change in condition prompting Psychiatric hospitalization as required, and it had not been.

Based on record review and interview, the facility failed to develop a baseline care plan for one Resident (#423) out of a total sample of 26 residents. Specifically, facility staff failed to develop a baseline care plan for Resident #423 as required, and did not develop a comprehensive care plan in its place within 48 hours of the Resident's admission to the facility. Findings include: Review of the facility policy for Baseline Care Plans, revised October 2022, indicated the facility developed baseline plan care plans within 48 hours of resident admissions to promote continuity of care and communication across disciplines. Resident #423 was admitted to the facility in May 2023 with diagnoses including Diabetes Type II and Myocardial Infarction (heart attack). Review of Resident #423's clinical record did not include any evidence that a baseline care plan had been developed for the Resident within 48 hours of his/her admission to the facility, or that a comprehensive care plan had been developed in place of the baseline care plan as required. During an interview on 7/20/23 at 4:00 P.M., Nurse #2 said baseline care plans were to be completed by the admitting Nurse. Nurse #2 reviewed Resident #423's clinical record with the surveyor and said no baseline care plan had been completed as required, but it should have been.

Based on observation, record review, and interview, the facility failed to provide an indwelling Foley/urinary catheter (a tube placed through the urethra into the bladder to drain urine) care, per professional standards of practice for one Resident (#380) out of a total sample of 26 residents. Specifically, the facility staff failed to obtain Physician's orders and develop a plan of care for the care and management of Resident #380's Foley catheter. Findings include: Resident #380 was admitted to the facility in June 2023 with a diagnosis of Extended Spectrum Beta-Lactamase (ESBL-enzyme found in some strains of bacteria that is resistant to antibiotics) in the urine. Review of the Centers for Disease Control's (CDC) Guidelines For Prevention of Catheter Associated Urinary Tract Infections 2009, reviewed 6/6/2019, indicated to consider implementing a system for documenting the following in the patient record: -indications for catheter insertion -date and time of catheter insertion -individual who inserted catheter -date and time of catheter removal Review of the facility policy titled Foley Catheter Care, revised 12/21/22, indicated: -It is the policy of the Jewish Healthcare Center that indwelling catheters will be clean and cared for according to current infection control standards. -Review Medical Doctor order to include appropriate diagnosis for foley catheter as well as size and balloon size. -Keep catheter drainage system and tubing free from kinks and covered with privacy bag. -Flush Foley catheter per MD orders for occlusion, signs of infection, encrustation. Review of the hospital Patient Care Referral to the facility, dated 6/29/23, indicated Resident #380 had urinary retention (inability to empty all the urine from the bladder) while in the hospital and a Foley catheter was placed on 6/28/23. Review of Resident #380's comprehensive care plan, initiated 6/29/23, did not include any information relative to the care and management of a Foley catheter. Review of the Minimum Data Set (MDS) assessment dated [DATE], Section H, indicated that the Resident had an indwelling urinary catheter. Review of Resident #380's July 2023 Physician's orders did not include any orders for the care and maintenance of the Foley catheter. On 7/18/23 at 4:04 P.M., the surveyor observed the Resident sitting in a chair next to his/her bed. The Resident had an indwelling urinary catheter tube that extended from the bottom of the Resident's pant leg that was connected to a urinary drainage bag. The drainage bag was observed attached to the bed frame. On 7/19/23 at 9:27 A.M., during an observation and interview, the surveyor observed the Resident dressed and lying in bed. There was a urinary catheter tube extending from the bottom of the Resident's pant leg and attached to the bed frame. Resident #380 said the Foley catheter was placed in the hospital before he/she was admitted to the facility. The Resident further said that the Foley catheter had not been changed since his/her admission to the facility. During a record review and interview on 7/19/23 at 10:52 A.M., Nurse #3 said the Resident had no orders for Foley catheter care and management. Nurse #3 further said the Resident should have had Physician's orders for Foley catheter care, including the catheter size and balloon size. During an interview on 7/19/23 at 11:19 A.M., the Director of Nursing (DON) said Resident #380 should have had Physician's orders for the care and management of the Foley catheter, but did not.

Based on observation, record review, and interview, the facility failed to provide care according to professional standards of practice for one Resident (#59) with a Gastrostomy tube (G-tube - also known as a feeding tube: medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake) out of three applicable sampled residents, in a total sample of 26 residents. Specifically, facility staff failed to administer enteral (delivery of nutrients through a feeding tube directly into the stomach) feedings according to the Physician orders, monitor and accurately record the amount of enteral feed administered to Resident #59, when the Resident was not allowed to take any nutrition by mouth (NPO), which increased the Resident's risk for reduced nutritional intake. Findings include: Resident #59 was admitted to the facility in December 2018 with diagnoses including anoxic (lack of oxygen) brain damage, Dysphagia (swallowing difficulty), and Gastrostomy status. Review of the facility's policy, titled Enteral Nutritional Therapy: Tube Feeding, revised 10/16/22, included: - It is the facility's policy to provide adequate nutrition via feeding tube when a resident is unable to take oral nutrition. - The amount of enteral feed administered was to be documented. Review of Resident #59's Nutrition Care Plan, initiated 7/1/21 and revised 2/9/23, included: - The Resident required 100% nutrition support related to Dysphagia, swallowing problem due to anoxic brain injury. - The Resident was at risk for malnutrition. - The Resident was dependent with tube feeding. Further review of the Nutrition Care Plan indicated the current tube feeding prescribed included: Give one liter of Jevity 1.2 Cal (calorically dense tube feeding formula) at 115 cubic centimeters (cc: unit of measurement) per hour (hr) until bottle is empty (up 8:00 P.M.) via G-tube . Review of the July 2023 Physician's orders included an active enteral feed order, initiated 7/21/22, as follows: In the evening give one liter of Jevity 1.2 Cal overnight at 115 cc/hr. Run until bottle is empty. Hang at 8:00 P.M. On 7/18/23 at 11:31 A.M., the surveyor observed a one liter bottle of Jevity 1.2 Cal which hung from the tube feed pole in Resident #59's room. The enteral feed formula bottle tube was not connected to the Resident's G-tube and the bottle had remaining enteral feed formula in it. The front of the bottle indicated it had been hung at 9:00 P.M. on 7/17/23. On 7/19/23 at 10:35 A.M., the surveyor observed a one liter bottle of Jevity 1.2 Cal which hung from the tube feed pole in Resident #59's room. The enteral feed formula bottle tube was not connected to the Resident's G-tube and the Resident was not in the room. The bottle had remaining enteral feed formula in it which the surveyor observed to be between 200 and 250 milliliters (ml [one ml is equivalent to one cc]), per the markings on the side of the bottle. The front of the bottle indicated it had been hung at 9:00 P.M. on 7/18/23. Review of Resident #59's July 2023 Medication Administration Record (MAR) indicated one liter of Jevity 1.2 Cal was administered overnight, starting at 8:00 P.M. on 7/17/23 and 7/18/23, and that the enteral feed formula ran until the bottle was empty. Review of Resident #59's clinical record included no evidence that facility staff monitored and accurately documented the amount of enteral feed formula administered to the Resident on 7/17/23 and 7/18/23, beginning on the evening (3:00 P.M. through 11:00 P.M.) shift and through the overnight shift (11:00 P.M. through 7:00 A.M.). During an interview on 7/19/23 at 10:35 A.M., Nurse #6 said the one liter bottle of Jevity 1.2 Cal was hung on the 7/18/23 evening shift and disconnected on the overnight shift. Nurse #6 then said she did not know why there was remaining enteral feed formula left in the bottle. During an interview on 7/19/23 at 11:34 A.M., Nurse #9 said Resident #59 did not always receive all of his/her enteral feed formula as ordered. Nurse #9 said this happened when the enteral feed formula bottle was hung later than 8:00 P.M. Nurse #9 said no matter what time the enteral feed formula bottle was hung, it had to be removed at 5:30 A.M. because the Resident's responsible party wanted it to be disconnected at that time. During an interview on 7/19/23 at 12:12 P.M., The Unit Manager (UM) said enteral feed pumps stored information relative to how much enteral feed formula was administered to residents. The UM said staff could monitor how much enteral feed formula was administered to residents by reviewing the stored information in the pump. He said in order for the pumps to be accurate, staff would have to clear the previous information stored in the pump before running more feeding. The surveyor and the UM observed Resident #59's enteral feed formula bottle at that time, which was in the Resident's room, dated 7/18/23 and had remaining feed in the bottle. The UM said the remaining enteral feed formula was approximately 250 ml. The UM also said 250 ml was a lot of enteral feed formula for Resident #59 not to receive. The UM then accessed the stored information on the enteral feed pump and said the stored information indicated the Resident had received 1800 ml of enteral feed formula within the last 11 hours, but that this was not accurate and was due to staff not clearing the previously stored information. The UM then said no residents on the Unit were on strict intake and output monitoring, and when asked how staff monitored for accuracy of enteral feed formula administration for Resident #59, he said, that's a good question. The UM further said he was unaware Resident #59 had not received his/her enteral feed as ordered on 7/18/23 and 7/19/23, from the evening shift through the overnight shift until the surveyor's inquiry. During an interview on 7/19/23 at 3:05 P.M., Nurse #8 said she recalled working the overnight shift within the previous two weeks, and that she worked with Resident #59 during that overnight shift but could not recall the exact date. Nurse #8 said she disconnected Resident #59's enteral feeding around 5:50 A.M. so that the Resident could receive incontinent care and medications via his/her G-tube. Nurse #8 said there was remaining enteral feed formula in the bottle, but she did not measure or record the amount left over, as required. Nurse #8 said she did not re-connect the enteral feed to the Resident or run the enteral feed until the bottle was empty. During an interview on 7/19/23 at 4:28 P.M., Nurse #7 said she worked the 11:00 P.M. through 7:00 A.M. (overnight) shift regularly and that Resident #59 was routinely on her assignment. Nurse #7 said she disconnected Resident #59's enteral feed every morning, around 5:30 A.M., when she worked so the Resident could have incontinent care and medications. Nurse #7 said she never reconnected the enteral feed for the Resident after disconnecting it for incontinent care and medications even if there was enteral feed formula left in the bottle. Nurse #7 said she did not record how much enteral feed formula was administered or how much was left over when she disconnected the enteral feed and there was remaining enteral feed formula left in the bottle because she thought the Resident's responsible party reconnected it after medications were administered to the Resident. During an interview on 7/21/23 at 12:45 P.M., the UM said he spoke with Resident #59's Nurse Practitioner (NP) on 7/19/23 once he became aware that the Resident did not always receive his/her ordered amount of enteral feed formula on the overnight shift. The UM said the NP provided no change in enteral feed orders and that the instruction provided by the NP was to ensure enteral feed formula was administered to the Resident as ordered.

Based on observation, record review, and interview, the facility failed to store all drugs in locked compartments, as required, for one Resident (#59) out of a total sample of 26 residents. Specifically, for Resident #59, the facility staff failed to store all drugs in a locked compartment when medications were observed stored in the Resident's room, not locked, and accessible to unauthorized persons. Findings include: Review of the facility's policy, titled Medication Storage in the Facility, dated December 2019, included: - Medications and biologicals are stored safely, securely, and properly . - The medication supply is accessible only to Licensed Nursing personnel, Pharmacy personnel, or staff members lawfully authorized to administer medications. Resident #59 was admitted to the facility in December 2018 with diagnoses including Gastrostomy (G-tube/ feeding tube- medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake) status, Dysphagia (swallowing difficulty), Spastic Quadriplegia, and cognitive communication deficit. Review of Resident #59's Activities of Daily Living (ADL) Care Plan, initiated 7/15/21 and revised 11/16/22, indicated the Resident was NPO (nil per os: nothing by mouth). Review of the Minimum Data Set (MDS) assessment, dated 4/26/23, indicated: - Resident #59 was rarely/never understood. - Completion of a staff assessment was required to determine Resident #59's mental status which indicated the Resident was severely cognitively impaired. - Resident #59 was dependent on staff for self care. On 7/19/23 at 10:30 A.M., the surveyor observed the following medications stored, unlocked and accessible to unauthorized personnel, in Resident #59's room: -one bottle of Chlorhexidine Gluconate (prescription) Oral Rinse USP (United States Pharmacopeial - organization that develops and disseminates public compendial quality standards for medicine) 0.12%. -one bottle of Nystatin (prescription to treat fungal infections) Oral Suspension USP 100,000 units per milliliter (ml). -one bottle of Biotene Dry Mouth Oral Rinse lined up on top of the nightstand which was positioned to the left side of the head of the bed. -one 0.5 fluid (fl) ounce (oz) bottle of artificial tears. -one 1.5 fl-oz bottle of Deep Sea Premium Saline Nasal Moisturizing Spray. -one eight fl-oz spray bottle of Hydrogen Peroxide First Aid Antiseptic. -one 15 gram (gm) bottle of Nyamic Nystatin (prescription antifungal medication) Topical Powder 100,000 USP units/gm. -one three oz bottle of Antifungal Powder stored on a rolling bedside table, which was positioned to the right side of the bed, next to the wall. During an interview on 7/19/23 at 10:35 A.M., Nurse #6 said Resident #59 was dependent on staff for self-care and administration of medications. Nurse #6 also said the Resident's responsible party was allowed to administer medications to Resident #59 per order of the Provider and that the medications the surveyor observed had been stored, unsecured, in the Resident's room for as long as she could remember. Nurse #6 said Resident #59 required total assistance from staff at the facility and that the Resident also had private duty personnel, not employed by the facility, who provided one to one services throughout the day and night. Nurse #6 said the medications stored on Resident #59's nightstand and bedside table were accessible to anyone who entered the room and should have been stored in a locked compartment as required, but they were not.

Based on observation, policy review, and interview, the facility failed to store food in accordance with professional standards for food service safety for two of nine applicable unit refrigerators. Specifically, the unit refrigerators on the 3 North Unit and the 3 East Unit contained expired and unlabeled food items. Findings include: Review of the facility policy titled Use & Storage of Foods Brought in by Family & Visitors, revised ,d+[DATE], indicated: -Food that needs refrigeration is stored in a container labeled with the patient's name, date and room number. -Any food unlabeled or beyond day three will be discarded On [DATE] at 7:55 A.M., the surveyor observed an open bag of organic pitted prunes with no name, dated [DATE], in the 3 East Unit refrigerator. During an interview on [DATE] at 8:00 A.M., Dietary Staff #1 told the surveyor that the prunes should have been discarded but they were not. On [DATE] at 9:08 A.M., the surveyor observed the following food items in the 3 North Unit refrigerator: -in the freezer, a clear plastic bag containing pieces of waffles and bread dated [DATE]. -in the freezer, a container of sorbet not dated with white frost covering the container. -in the refrigerator, a white plastic container of cottage cheese with a printed expiration date of [DATE] on the bottom. -in the refrigerator, an open cardboard cake box with no date containing a small piece of dried out cut up cake. During an interview on [DATE] at 9:12 A.M., Dietary Staff #1 said that the plastic bag with the waffles, sorbet, cottage cheese, and cake should have been removed from the refrigerator and discarded but they were not. She further said that she was aware of the policy to label food properly with a residents name and the date when the item was put into the refrigerator, and then to discard food after it had been in the refrigerator for three days.

Based on record review and interview, the facility failed to provide education, assess for eligibility, and offer Pneumococcal immunization per the Centers for Disease Control and Prevention (CDC) recommendations for four Residents (#1, #3, #4, and #5) out of a total sample of five residents. Findings include: Review of the facility policy titled Immunization: Influenza and Pneumonia, last revised 5/11/23, indicated the following: -It is the policy of the Jewish Healthcare Center to offer vaccines to all patients/residents admitted to the facility, and to educate the elderly population regarding the flu and Pneumonia vaccine, stressing the need to build their immune system thru immunization. -Pneumonia to be given when needed. -Pneumonia will be asked annually . Review of the CDC website Pneumococcal Vaccine Timing for Adults (https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf), dated 3/15/23 indicated the following: -For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last pneumococcal vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20) . 1. Resident #1 was admitted to the facility in May 2023 and was over the age of 65. Review of the Resident's Massachusetts Immunization Information System (MIIS) Vaccine Administration Record indicated the Resident had received the PCV13 on 2/26/16 and the PPSV23 on 12/4/03. Review of the Resident's medical record indicated no additional documentation the Resident and/or the Resident's Representative had been educated or offered any additional CDC recommended Pneumococcal Vaccination. 2. Resident #3 was admitted to the facility in March 2020 and was over the age of 65. Review of the Resident's MIIS Vaccine Administration Record indicated the Resident had received the PCV13 on 3/4/16 and the PPSV23 on 11/15/06. Review of the Resident's medical record indicated no additional documentation the Resident and/or the Resident's Representative had been educated or offered any additional CDC recommended Pneumococcal Vaccination. 3. Resident #4 was admitted to the facility in May 2008 and was over the age of 65. Review of the Resident's immunization section in the electronic medical record (EMR) indicated the Resident had received the PCV13 on 11/21/17 and the PPSV23 on 12/7/07. Review of the Resident's medical record indicated no additional documentation the Resident and/or the Resident's Representative had been educated or offered any additional CDC recommended Pneumococcal Vaccination. 4. Resident #5 was admitted to the facility in August 2022 and was over the age of 65. Review of the Resident's MIIS Vaccine Administration Record indicated the Resident had received the PCV13 on 3/16/15. Review of the Resident's immunization section in the EMR indicated the Resident had received the PPSV23 on 1/28/97. Further review of the Resident's medical record indicated no additional documentation the Resident and/or the Resident's Representative had been educated and/or offered any additional CDC recommended Pneumococcal Vaccination. During an interview on 6/13/23 at 11:27 A.M., the Assistant Director of Nursing (ADON) said the facility currently did not have a process in place to educate and offer the Residents and/or Resident Representative's the recommended PCV20. During an interview on 6/13/23 at 12:50 P.M., the Medical Director said the facility had begun talking about rolling out (giving) the PCV20 but had not yet implemented a plan to do so. She further said the facility wanted its residents to be as protected as possible and for immunocompromised residents and those who had not had a Pneumococcal Vaccination in five or more years, she felt those residents could benefit from updated vaccination. She also said when a new recommendation for vaccination comes out, it should be followed up on as soon as possible. During an interview on 6/13/23 at 1:16 P.M., the ADON said at this time Residents #1, #3, #4, and #5 had not been offered education or the opportunity to receive the PCV20 vaccination as recommended.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was assessed by nursing as being at an increased risk for falls and who required the use of a personal alarm while in a chair, the facility failed to ensure interventions related to maintaining Resident #1's safety were consistently implemented by staff. On 11/06/22, after transferring Resident #1 into a stationary recliner at the nurses' station, his/her chair alarm was not put in place. Resident #1 was able to get up undetected and fell . Resident #1 sustained four fractured ribs, as a result of the fall. Findings include: Review of the Facility's Policy, titled Alarms and Safety Devices, dated as revised 12/13/21, indicated if a resident is assessed as high risk for falls with a score of 13 or higher on the fall assessment, or have demonstrated incidences of self-transferring, increased confusion or significant change in condition, safety devices may be used including but not limited to auditory alarms, low beds, spatial boundary reminders such as bolsters, self-releasing seatbelts or alarmed self-releasing belts. The Policy indicated if it has been determined that an alarm is necessary to aid in the safety of a resident, a Physician order must be obtained and noted in the chart, intervention placed on the care plan and the alarm will be noted on the alarm check off sheet. Resident #1 was admitted to the Facility in March 2021, medical diagnoses included dementia, orthostatic hypotension (lightheadedness or dizziness when standing after sitting or lying down), history of falls, and age related osteoporosis without current pathological fracture (bone density disorder). Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 10/26/22, indicated that he/she was moderately cognitively impaired, with a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS indicated Resident #1 utilized a bed and chair alarm daily, and required extensive assistance from one staff member for transfers and ambulation with a walker. Review of Resident #1's Physician's Orders, for November 2022, indicated he/she had orders dated effective 07/12/22, for a bed and chair alarm, to check for placement every shift, and change batteries every 60 days. Review of Resident #1's Fall Risk Assessment, dated 10/21/22, indicated he/she was at an increased risk for falls. Review of Resident #1's Fall Risk Care Plan, dated as revised 10/28/22, indicated that he/she was at an increased risk for falls due to muscle weakness, poor cognition, occasional incontinence, and psychotropic medication use. The Care Plan indicated that Resident #1 had a previous fall with a right femur (thigh bone) fracture in September 2021. The Care Plan included a goal to keep Resident #1 free from fall related injuries, interventions included that he/she utilized bed and chair alarms, and to ensure the device (s) are in place and functioning. Review of the Facility's Incident Report, dated 11/06/22, indicated Resident #1 was found lying on the floor at 2:20 P.M., next to a recliner across from the nurses' station. The Report indicated Resident #1 tried to ambulate without assistance and an alarm (chair alarm) was not in place to alert staff that he/she was in motion. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/17/22, indicated that on 11/06/22 at 2:20 P.M., Resident #1 was found lying on the floor on his/her right side in front of the nurses' station. On 11/09/22, Resident #1 began complaining of right sided shoulder and trunk pain. An x-ray showed fractures of the right sided ribs, numbered seven through ten. The Report concluded that prior to the fall on 11/06/22, Certified Nurse Aide (CNA) #1 did not place his/her chair alarm in the recliner chair, where she seated Resident #1 after taking him/her to the bathroom. Review of Resident #1's x-ray report, dated 11/09/22, indicated acute, displaced fractures of the right lateral ribs, numbered seven through ten, with mild tissue swelling. During an interview on 12/01/22 at 12:20 P.M., the Unit Manager said Resident #1 had poor safety awareness, impulsivity, and a history of falling. The Unit Manager said Resident #1 had a pattern of self-rising and was encouraged to sit in supervised areas. The Unit Manager said Resident #1 was care planned for an alarm when in bed and when in a chair, because he/she was at an increased risk for falls. During an interview on 12/02/22 at 7:43 A.M., Certified Nurse Aide (CNA) #1 said she worked the day shift on 11/06/22 and was assigned to assist residents with activities, eating and toileting. CNA #1 said she was ambulating Resident #1 from the bathroom back to his/her wheelchair in the activity room, when he/she insisted on sitting in a recliner that was across from the nurses' station instead. CNA #1 said she seated Resident #1 in the recliner and returned to the activity room. During an interview on 12/02/22 at 11:14 A.M., Nurse #1 said on 11/06/22 in the late afternoon she was charting in a room adjacent to the nurses' station when she heard someone call out that a resident had fallen. Nurse #1 said she responded immediately and found Resident #1 lying on his/her right side on the floor next to a recliner, across from the nurses' station. Nurse #1 said there was no chair alarm in place. CNA #1 said on 11/06/22 she heard a commotion around 2:20 P.M. and observed through the open door of the activity room, that Resident #1 was on his/her right side on the floor near the nurses' station. CNA #1 said it was at that time she realized she had forgotten to move Resident #1's chair alarm from his/her wheelchair in the activity room to the recliner where he/she was seated. During an interview on 12/01/22 at 2:12 P.M., Nurse #2 said she worked as the charge nurse on the day shift on 11/06/22. Nurse #2 said that while she was charting that afternoon, she observed CNA #1 seat Resident #1 in a recliner across from the nurses' station. Nurse #2 said she was not aware that Resident #1's chair alarm had not been put in place when he/she was seated at the nurses' station. Nurse #2 said Resident #1 always required a chair alarm because he/she was impulsive and often stood without warning. During an interview on 12/01/22 at 1:49 P.M., the Director of Nurses (DON) said the conclusion to the facility's investigation of Resident #1's fall on 11/06/22, that resulted in four fractured ribs, was that CNA #1 had not implemented the care plan for Resident #1 pertaining to the use of a chair alarm. The DON said the expectation was that Resident #1's chair alarm should have been moved from his/her wheelchair in the activity room, to the recliner across from the nurses' station where he/she was seated. The DON also said that the nurses' station should not be left unattended by staff when residents are seated in the recliners that are located across from it.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was assessed by nursing as being at an increased risk for falls, and whose care plan for safety included the use of a chair alarm, the Facility failed to ensure his/her assistive device was in place to prevent incidents and/or accidents resulting in an injury. On 11/06/22, after transferring and seating Resident #1 in a recliner near the nurses' station, Certified Nurse Aide (CNA) #1 did not put his/her chair alarm in place, Resident #1 was able to get up undetected by staff, fell , and was found lying on the floor on his/her right side. Resident #1 sustained four fractured ribs, as a result of the fall. Findings include: Review of the Facility's Policy, titled Accident Management, dated as revised 09/01/22, indicated that it is the policy of the Facility to ensure that residents remain in an environment free from hazards. To assess for residents who are at risk for accidents and/or falls so adequate supervision and assistive devices are implemented to reduce the risk of incidents, falls and/or injury related to either incidents and/or falls. Review of the Facility's Policy, titled Alarms and Safety Devices, dated as revised 12/13/21, indicated if a resident is assessed as high risk for falls with a score of 13 or higher on the fall assessment, or have demonstrated incidences of self-transferring, increased confusion or significant change in condition, safety devices may be used including but not limited to auditory alarms, low beds, spatial boundary reminders such as bolsters, self-releasing seatbelts or alarmed self-releasing belts. The Policy indicated if it has been determined that an alarm is necessary to aid in the safety of a resident, a Physician order must be obtained and noted in the chart, intervention placed on the care plan and the alarm will be noted on the alarm check off sheet. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 11/17/22, indicated that on 11/06/22 at 2:20 P.M., Resident #1 was found lying on the floor on his/her right side in front of the nurses' station. On 11/09/22, Resident #1 began complaining of right sided shoulder and trunk pain. An x-ray showed fractures of the right sided ribs, numbered seven through ten. The Report concluded that prior to the fall on 11/06/22, Certified Nurse Aide #1 did not place a chair alarm in the recliner chair, where she seated Resident #1 after taking him/her to the bathroom. Resident #1 was admitted to the Facility in March 2021, medical diagnoses included dementia, orthostatic hypotension (lightheadedness or dizziness when standing after sitting or lying down), history of falling, age related osteoporosis without current pathological fracture (bone density disorder). Review of Resident #1's Fall Risk Assessment, dated 10/21/22, showed a score of 11 which indicated he/she was at an increased risk for falls. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 10/26/22, indicated that he/she was moderately cognitively impaired, with a score of 11 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS indicated Resident #1 utilized a bed and chair alarm daily and required extensive assistance from one staff member for transfers and ambulation with a walker. Review of Resident #1's Physician's Orders, for November 2022, indicated he/she had orders dated effective 07/12/22, for a bed and chair alarm, to check placement every shift, and change batteries every 60 days. Review of Resident #1's Fall Risk Care Plan, dated as revised 10/28/22, indicated that he/she was at an increased risk for falls due to muscle weakness, poor cognition, occasional incontinence, and psychotropic medication use. The Care Plan indicated that Resident #1 had a previous fall with a right femur (thigh bone) fracture in September 2021. The Care Plan included a goal to keep Resident #1 free from fall related injuries, and interventions included the use of bed and chair alarms, ensure the device (s) are in place, and functioning. Review of the Facility's Incident Report, dated 11/06/22, indicated Resident #1 was found lying on the floor at 2:20 P.M., next to a recliner across from the nurses' station. The Report indicated Resident #1 tried to ambulate without assistance and an alarm was not in place to alert staff that he/she was in motion. Review of Resident #1's x-ray report, dated 11/09/22, indicated acute, displaced fractures of the right lateral ribs, numbered seven through ten, with mild tissue swelling. During an interview on 12/01/22 at 12:20 P.M., the Unit Manager said Resident #1 had poor safety awareness, impulsivity, and a history of falling. The Unit Manager said Resident #1 had a pattern of self-rising and was encouraged to sit in supervised areas. The Unit Manager said Resident #1 was care planned for an alarm when in bed and when in a chair, because he/she was at an increased risk for falls. During an interview on 12/02/22 at 7:43 A.M., Certified Nurse Aide (CNA) #1 said she worked the day shift on 11/06/22 and was assigned to assist residents with activities, eating and toileting. CNA #1 said she was ambulating Resident #1 from the bathroom, back to his/her wheelchair in the activity room, when he/she insisted on sitting in a recliner that was across from the nurses' station instead. CNA #1 said she seated Resident #1 in the recliner and returned to the activity room. During an interview on 12/02/22 at 11:14 A.M., Nurse #1 said on 11/06/22 around 2:20 P.M., she was charting in a room adjacent to the nurses' station when she heard someone call out that a resident had fallen. Nurse #1 said she responded immediately and found Resident #1 on the floor lying on his/her right side next to a recliner, across from the nurses' station. Nurse #1 said there was no chair alarm in place. CNA #1 said she heard a commotion around 2:20 P.M. and observed, through the open door of the activity room, that Resident #1 was on the floor, on his/her right side near the nurses' station. CNA #1 said it was at that time she realized she had forgotten to move Resident #1's chair alarm from his/her wheelchair in the activity room to the recliner where he/she was seated. During an interview on 12/01/22 at 2:12 P.M., Nurse #2 said she worked as the charge nurse on the day shift on 11/06/22. Nurse #2 said that while she was charting that afternoon, she observed CNA #1 seat Resident #1 in a recliner across from the nurses' station. Nurse #2 said she was not aware that Resident #1's chair alarm was not in place. Nurse #2 said Resident #1 always required a chair alarm because he/she was impulsive and often stood without warning. During an interview on 12/01/22 at 1:49 P.M., the Director of Nurses (DON) said the conclusion of the facility's investigation of Resident #1's fall on 11/06/22, that resulted in four fractured ribs, was that CNA #1 had not followed the care plan for Resident #1 pertaining to the use of a chair alarm. The DON said the expectation was that Resident #1's chair alarm should have been moved from his/her wheelchair in the activity room, to the recliner across from the nurses' station where he/she was seated. The DON further said that the nurses' station should not be left unattended when residents are seated in the recliners that are located across from it.