Jordan Rehabilitation and Healthcare Center

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to follow the care plans for 1 of 3 sampled residents, Resident (R) 4. Resident 4 was identified as requiring a mechanical lift for transfers on her care plan. On 05/21/2026, during interview with Licensed Practical Nurse (LPN) 1, she stated CNA8 and CNA9 transferred R4 to the bed without using a mechanical lift on 05/08/2026.The findings include:Review of the facility's policy titled, Comprehensive Care Plans, 2025 revision, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and services that were identified in the resident's comprehensive assessment and meet professional standards of quality.Review of R4's admission Record revealed the facility admitted the resident on 01/16/2023 with diagnoses to include dementia, stroke, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure each resident's right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 6 of 28 sampled residents, Resident (R) 7, R9, R10, R28, R76, and R82.Review of each resident's document Behavior Modification Consent revealed the name of the medication, risks and benefits of the medication, and treatment alternatives/options were not specified.The findings include:Review of the facility's document Resident Rights, undated and found in the facility's admission packet, revealed the resident had a right to be informed of and participate in their treatment, which included the right to be fully informed in advance of the risks and benefits of proposed care, of treatment, and treatment alternatives.1. Review of R82's admission Record revealed the facility admitted R82 on 05/11/2012 with diagnoses of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, information from the Centers for Disease Control and Prevention (CDC), and review of the facility's policies, the facility failed to establish and maintain 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 for 7 of 40 sampled and supplemental residents, Resident (R) 66, R77, R35, R13, R42, R71, and R33.R66 was diagnosed with a communicable skin infection on 04/10/2026 and a contact precautions order was placed by the physician. However, observation on 04/14/2026 revealed no transmission-based precaution signage posted outside R66's room, and after Contact Precaution signage was posted, staff entered the room without donning (putting on) required personal protective equipment (PPE). Observation on 04/14/2026 revealed the common sinks shared between two resident-occupied rooms by R77, R35, and R13 were completely covered in clear plastic and inaccessible for use.Observations on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, review of the facility's job description, and review of the facility's document and policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 9 sampled residents, Resident (R) 10, R17, and R28, related to falls.The findings include:Review of the facility's undated policy titled, Comprehensive Care Plans [CCP], revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that were identified in the resident's comprehensive assessment and met professional standards of quality but were not provided due to the resident's exercise of his/her right to refuse. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide necessary activities of daily living care to maintain 1 of 2 sampled dependent residents in a clean manner, Resident (R) 11. The facility failed to ensure R11 had clean clothing, clean bed linens, and grooming assistance. The findings include:Review of the facility's policy titled, Activities of Daily Living [ADL] dated 2025, revealed the facility would provide care and services consistent with each resident's comprehensive assessment, needs, and choices. The policy further stated residents unable to perform activities of daily living would receive necessary services for bathing, dressing, grooming, and personal hygiene.Review of R11's admission Record revealed the facility admitted R11 on 10/18/2024 with diagnoses of dementia, atrial fibrillation, and limited mobility.Review of R11's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 02/12/2026, revealed R11 was severely cognitively impaired, had no Brief Interview for Mental Status [BIMS]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, review of the Activity Director job description, and review of the facility's policy, the facility failed to provide an ongoing program to support the residents' choice of activities based on their comprehensive assessment, care plan, and preferences, specifically one-to-one interaction, as directed for 2 of 2 sampled residents, Resident (R) 12 and R13. Observations from 04/14/26 through 04/16/2026 revealed R12 and R13 were in bed, dressed in bed clothing or a shirt only. No observations were made of staff providing one-to-one interaction.The findings include:Review of the undated policy titled Activities, revealed the facility provided an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. It also stated individual activities would be designed to support their physical, mental, and psychosocial well-being and encourage interaction within the community. Review of the undated job description for the Activity Director (AD) revealed it was the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the facility's daily bedtime snack list, and review of the scientific article referenced by the National Institute of Health (NIH), the facility failed to provide substantial snacks to residents who needed assistance at meals as determined by review of the time between supper and breakfast was greater than 14 hours. Review of the facility meal service times, not dated, revealed total assist residents received supper at 4:30 PM and breakfast at 7:00 AM. The findings include: Review of the scientific article referenced by the National Institute of Health (NIH) in Nutrients titled What is Nutritious Snack Food? A Comparison of Expert and Layperson Assessments? 2017 [DATE]; 9(8):874 revealed the definition of a nutritious snack that contained preferred nutrients was food with a high percentage of essential nutrients relative to the energy content. Observation on 06/04/2025 at 8:10 AM revealed there was no ice cream observed in the [NAME] Unit nourishment refrigerator…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, review of the United States Department of Agriculture (USDA) web site, and review of the facility's policies, the facility failed to store and serve food in a safe manner as determined by observations during the initial tour on 05/02/2025. These observations revealed food not labeled or dated in the dry storage, walk-in refrigerator, and the freezer. In addition, observations of the supper meal tray line on 06/02/2025 at 4:16 PM revealed the Dietary Manger and [NAME] improperly used the food thermometer, and Dietary Aide 1 used open utility carts with a wet top shelf. This had the potential to affect 92 residents that received food from the kitchen. The findings include: Review of the facility's policy titled, Food Storage, dated 2010, revealed all stock must be rotated with each new stock received. Per the policy, rotating stock was essential to ensure the freshness and highest quality of all foods. The policy stated old stock was always used first (first in-first out method), and food should be dated as it was placed onto the shelf. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, review of the Postal Service Reform Act of 2022, and review of the facility's policy, the facility failed to ensure residents the right to receive mail, letters, and packages delivered to the facility. In interviews with Resident Council members, they stated they did not receive mail on Saturdays. This practice had the potential to affect all current 92 residents. The findings include: Review of the facility's policy titled, Resident's Rights For Residents in [State] Long-Term Care Facilities, not dated, revealed the resident had a right to exercise his or her rights as a resident of the facility and as a citizen of the United States. Review of the Postal Service Reform Act of 2022 (PSRA) confirmed mandated six-day mail delivery services (Monday through Saturday). In an interview with Resident (R) 71 during the Resident Council meeting on 06/03/2025 at 10:00 AM, the resident stated there was no one to bring mail to residents on Saturdays. In an interview with R12 during the Resident Council meeting on 06/03/2025 at 10:00 AM, she stated she knew of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 1 of 24 sampled residents, Resident (R) 81. R81's Comprehensive Care Plan (CCP) stated his preference for individual activities. It did not, however, reflect any history of service-related, post-traumatic stress disorder (PTSD) potential triggers, or how to address them. The findings include: Review of the facility's policy titled, Care Planning - Interdisciplinary Team, revised 09/2013, stated the facility's Care Planning/Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan (CCP) for each resident. Review of R81's admission Record revealed the facility admitted the resident on 03/26/2025 with diagnoses of end stage renal disease…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the U.S. Food and Drug Administration's (FDA) guidelines, the facility failed to ensure the resident environment remained as free of accident hazards as was possible to ensure the safety of 1 of 5 residents reviewed for vaping safety. Observation on 06/02/2025 revealed R62 using a vape (e-cigarette) while wearing a nasal cannula that was delivering four liters of oxygen (O2) with R44 exposed to R62's second hand vaping aerosol. The findings include: Review of the facility's policy titled, Electronic Cigarettes Policy [e-cig, vape, vapor pen], undated, revealed the vaping policy did not address oxygen use. Further review revealed there was no provision for the storage of Nicotine liquid (e-juice), and the policy did not address the exposure risk of others to second hand smoke. Review of the U.S. Food and Drug Administration's (FDA) guidelines, Tips to Help Avoid Vape Battery Fires or Explosions, dated 04/12/2024, revealed there could be added dangers, for example, if a vape battery caught fire or exploded near flammable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, review of the manufacturers' directions for use (DFU), and review of the facility's policies, the facility failed to establish and maintain 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 for 1 of 24 sampled residents, Resident (R) 46. Observation on 06/03/2025 revealed R46's tube feeding, tubing, and continuous bladder irrigation tubing were left uncovered when disconnected from the resident. The findings include: Review of the facility's policy titled, Infection Control Program, last review date 08/24/2024, revealed the primary purpose of the facility's infection control program policies and procedures was to establish guidelines to follow to provide a safe and sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. It also stated it was the responsibility of the process improvement (PI) committee, through the Infection Control…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, review of a Centers for Disease Control and Prevention (CDC) document, and review of the facility's policy, the facility failed to develop and implement effective policies to ensure the smoking safety for all residents that used electronic cigarettes (e-cigarettes or vapes) for 1 of 5 residents that used e-cigarettes, Resident (R) 62 and R44, who was exposed to R62's second hand vaping aerosol. Observation on 06/02/2025 at 2:50 PM revealed R62, with R44 present, using a vape while wearing a nasal canula that was delivering four liters of oxygen (O2), and the facility's vaping policy did not address oxygen use or the exposure risk of others to second hand smoke. Refer to F689 The findings include: Review of the facility's policy titled, Electronic Cigarettes Policy [e-cig, vape, vapor pen], undated, revealed the vaping policy did not address oxygen use. Further review revealed there was no provision for the storage of Nicotine liquid (e-juice), and the policy did not address the exposure risk of others to second hand smoke. Review of a CDC document…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.