Robison Jewish Health Center

In the surveyor’s words

From the most serious findings on record at Robison Jewish Health Center, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 4, 2025

  Based on interviews and record review it was determined the facility failed to ensure a Stage 2 pressure ulcer was identified, assessed, treated and monitored upon admission to the facility for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. As a result, Resident 1 experienced significant damage to her/his penis, which was unrepairable and resulted in the resident no longer being able to urinate from her/his penis. Findings include:Resident 1 admitted to the facility on 8/2025 with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, a foley catheter, and a Stage 2 pressure ulcer located on the resident's penis.Per CMS, a Stage 2 Pressure Ulcer is defined as a partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. […]

• Actual harm, isolatedF689Aug 2, 2024

  Based on interview and record review it was determined the facility failed to implement interventions to prevent a fall for 1 of 3 sampled residents (# 20) reviewed for accidents. This failure resulted in Resident 20 having a fall with serious injury including a head hematoma (a pool of blood under the skin), a gluteal hematoma, multiple rib fractures and skin avulsions (skin tears) which required emergency medical services and treatment at the hospital. Findings include: Resident 20 was admitted to the facility 12/2020 with diagnoses including dementia and anxiety. Resident 20's 12/10/23 Annual MDS indicated Resident 20 was noted to have wandering behavior and was exit seeking. A 4/17/24 Behavior and Psychotropic Meeting Note indicated Resident 20 exhibited wandering behaviors. […]

• Actual harm, isolatedF689Apr 21, 2023

  Based on observation, interview and record review it was determined the facility failed to safely transfer a resident with the use of a mechanical device for 1 of 1 sampled resident (#301) reviewed for accidents. This failure resulted in Resident 301 falling during a transfer and was hospitalized with a subdural hematoma (a pool of blood between the brain and its outermost covering). Findings include: Resident 301 was admitted to the facility in 11/2022 with diagnoses including atrial fibrillation. […]

• No harm, potential for more than minimal, widespreadF880Sep 22, 2025

  Based on interview and record record it was determined the facility failed to monitor for legionella in 1 of 1 facility reviewed for infection control. This placed residents at risk for infection from exposure to water borne pathogens. Findings include:The facility's Infection Prevention and Control Program policy and procedure dated 10/1/25 indicated:- A water management program has been established as part of the overall infection prevention and control program, - Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems, and- The Maintenance Director serves as the leader of the water management program. […]

• No harm, potential for more than minimal, widespreadF725Aug 2, 2024

  Based on interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: The facility's revised 4/2007 Staffing Policy indicated the facility provided adequate staffing to meet the needed care and services of the residents. On 7/29/24 the facility had a census of 39 residents in four houses (each house was a self-contained unit). […]