Jewish Home and Care Center

In the surveyor’s words

From the most serious findings on record at Jewish Home and Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF578Apr 6, 2026

  Based on interview and record review, the facility did not ensure residents' advanced directives were implemented. This was observed with 2 (R102 and R24) of 2 residents reviewed for advanced directives. The failure to implement advanced directives has the potential to affect all 82 residents in the facility. * R102 elected a DNR (Do Not Resuscitate) status, and the paperwork was not processed as required. The facility did not honor R102's request and R102 received CPR on [DATE]. * R24 completed paperwork to request a Do Not Resituate (DNR) status and the facility did not honor this request and performed Cardiopulmonary Resuscitation (CPR). The facility's failure to honor residents' advance directives requesting no CPR created a finding of Immediate Jeopardy that began on [DATE]. […]

• Immediate jeopardy, isolatedF684Apr 6, 2026

  Based on observation. interview, and record review the facility did not provide care consistent with standards of practice by failing to ensure changes in medical conditions were immediately addressed. This was observed with 2 (R24 and R17) of 18 resident record reviews. *R24 received fish for lunch and has a documented allergy to fish. After consuming some of fish R24 experienced a low heart rate and became unconscious. Staff failed to administer anaphylaxis interventions immediately. Staff texted R24's Medical Doctor (MD)-X with the observed change in condition and did not call for consultation. […]

• Immediate jeopardy, isolatedF806Apr 6, 2026

  Based on record review and interview, the facility did not ensure a resident's food allergy, once identified, was thoroughly assessed to determine how best to manage the resident's allergy and to ensure the resident did not receive food to which the resident was allergic. This was observed with 1(R24) of 1 resident experiencing a food allergy response.*R24 had a documented allergy to fish. R24 was served fish for lunch on 3/15/26 and experienced an anaphylactic response that was not identified and treated as anaphylaxis and R24 passed away at the facility.This created a finding of Immediate Jeopardy that began on 3/15/26. Nursing Home Administer (NHA)-A and Director of Nurses (DON) -B were notified of the Immediate Jeopardy on 3/26/26 at 10:40 AM. […]

• Actual harm, isolatedF686Apr 6, 2026

  Based on observation, interview and record review, the facility did not ensure that residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing or worsening for 1 (R98) of 5 residents reviewed for pressure injuries.*R98 was assessed on admission to be at risk for the development of pressure injuries. R98 developed an avoidable, unstageable pressure injury to the coccyx. R98's admission wound assessment completed on 3/5/26 documented a Stage 1 wound to R98's coccyx. R98's baseline care plan documented a barrier cream intervention with no further instructions for use and no other interventions in place to prevent pressure injury decline. […]

• Actual harm, isolatedF760Aug 22, 2024

  Based on interview and record review, the facility did not ensure 1 of 3 sampled residents (R2) was free from significant medication errors. * R2 received a medication, Morphine, on 05/26/2024, which is not on R2's Medication Administration Record (MAR) and is not prescribed to R2. After administration, this medication required close monitoring of R2's physiological status. *R2 had orders for Clonazepam, oral tablet, 0.5mg to be given two times per day (AM and PM) for Anxiety. On 05/21/2024, R2 received 1 mg of Clonazepam during the PM medication pass instead of 0.5mg as prescribed. […]