Recuperative Services Unit-Hebrew Rehab Center

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired, unable to give consent and had an activated Health Care Proxy (HCP), the facility failed to ensure Resident #1 was treated in a dignified and respectful manner, when on 12/22/25 during the day shift, Resident #1's hair had been cut (which was against his/her cultural beliefs) by a staff member, and was cut without consent from his/her Health Care Agent (HCA).Findings include:Review of the Facility's Policy titled Patient [NAME] of Rights and Responsibilities, dated as approved 07/22/25, indicated the following:-ensure all patients are treated fairly with consideration of individual needs and respecting their rights.-staff is committed to provide high quality care while respecting the rights, individuality, dignity, and culture of each patient.-if there is a suspected instance where we failed to meet these goals, or if a patient or family member feels that rights have been violated, they are encouraged to discuss their concerns with the people involved…

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 record review and interview, the facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 2 2025 (January 1 - March 31), in accordance with the schedule specified by CMS.Findings include:Review of the Payroll Based Journal (PBJ) Staffing Report, CASPER Report 1705D, FY Quarter 2 2025 (January 1 - March 31), indicated the facility failed to submit data for the quarter.Review of the facility's submission report titled 'CMS Payroll Based Journal - Upload Data File', dated 5/7/25, indicated a submission had been made for PBJ data. This submission report indicated:-Your submission has been received and will be checked for errors within 24 hours.-Note: This screen does not confirm that your submission is error free.-This is a reminder to: Check CASPER for a system generated PBJ File Validation Report within 24 hours.During an interview on 7/23/25 at 7:13 A.M., the Quality and Regulatory Compliance Nurse said she was responsible for submitting the PBJ…

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, policy review, and interview, the facility failed to serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure staff did not use contaminated gloves to directly handle ready-to-eat food. Findings include: Review of the facility's policy titled Personal Hygiene and Uniforms, revised January 2024, indicated, but was not limited to, the following: -Culinary and Nutrition Staff will adhere to the highest standard of personal hygiene. -Proper hand washing is the single most effective way to minimize the transfer of food-borne illness. All staff must wash their hands frequently and particularly in the following situations: After coming in contact with any soiled utensil, equipment or surface and before touching anything unsoiled. On 7/17/24 from 7:49 A.M. to 8:03 A.M., the surveyor made the following observations during a continuous tray line observation during breakfast service: -The cook contaminated his gloves by picking up a toaster and moving it, he then further contaminated his gloves by touching a…

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 observations, interviews, and record review, the facility failed to implement the plan of care for one Resident (#434) out of a total sample of 12 residents. Specifically, the facility failed to provide supervision with eating for Resident #434. Findings include: Resident #434 was admitted to the facility in July 2024 with diagnoses including failure to thrive and dysphagia (difficulty swallowing). Review of the most recent Minimum Data Set (MDS) assessment, dated 7/16/14, indicated Resident #434 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Review of Resident #434's plan of care related to dysphagia, dated 7/16/24, indicated: - Supervision recommendations: 100% of the time, need for cueing, Encourage self-feeding. - Supervision: Feeds self with close, line of sight/direct supervision to load to utensil with food, encouragement to continue eating. Review of the speech therapy evaluation, dated 7/12/24 and signed by the physician on 7/14/24, indicated: - Pt (patient) presents with presbyphagia (age-related…

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 record review, interview and observation for one Resident (#81) of 12 sampled residents, the facility failed to provide respiratory care consistent with professional standards of practice. Specifically, the facility failed to develop a resident care policy for oxygen administration and failed to obtain a physician's order for oxygen use, which staff were actively administering to the Resident. Findings include: Review of the Healthcare Quality Association on Accreditation, dated 5/4/2017, indicated physician orders must be obtained for oxygen use and should include the amount of oxygen (flow rate) and duration. Review of policies indicated the facility had not developed a policy for oxygen use. Resident #81 was admitted to the facility in June 2024, and had diagnoses which included chronic obstructive pulmonary disorder (COPD, a lung disease limiting the ability to breath), dyspnea (labored breathing) and multiple fractured ribs. Review of Resident #81's Minimum Data Set assessment, dated 7/9/24, indicated there was no reference to use of oxygen therapy. Review of Resident…

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, policy review, record review and interview for one Resident (#18) of 12 sampled residents, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal requirements. Specifically, for Resident #18 the facility failed to ensure nursing stored his/her physician's ordered nasal spray and timolol (medicated eye drops used to treat high pressure in the eyes) according to State and Federal requirements. Findings include: Review of the facility policy, Medication Storage, Security and Access, dated as revised 10/25/21, indicated all medications will be stored and secured in accordance with all state and federal regulations. Medications stored in patient care areas: 1. Medication storage areas are accessible only to authorized personnel, as designated by the Director of Pharmacy. 2. All medications are stored in a secured location or in an area where the medication storage area is under continuous surveillance by licensed personnel. The Director of Pharmacy has authority to designate storage areas for all medications. 3.…

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, record review and interviews, the facility failed to implement a personalized mood care plan for 1 Resident (#1A) out of a sample of 13 Residents. Findings include: Review of the facility policy titled 'Nursing Documentation Policy' with a revision date of 12/13/21 indicated the following: *A care plan will be initiated for active problems and updated regularly, and when change in condition is noted. *Care plans will be initiated during change in condition and include individualized care plans with person specific approaches. Review of the facility policy titled 'Medical Management' with no revision date, indicated the following: *Upon admission to the Recuperative Services Unit, each patient is assessed by our team of professionals including case managers/social workers and psychiatrists. *At the conclusion of the assessment process, the team initiates a plan of care to be followed during the patient's stay, depending on the care needs of the patient, the following clinical specialties are…

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, record review and interview, the facility failed to make a psychiatric service referral for 1 Resident (#1A) out of a sample of 13 Residents. Findings include: Review of the facility policy titled 'Medical Management' with no revision date indicated the following: *Upon admission to the Recuperative Services Unit, each patient is assessed by our team of professionals including case managers/social workers and psychiatrists. *At the conclusion of the assessment process, the team initiates a plan of care to be followed during the patient's stay, depending on the care needs of the patient, the following clinical specialties are also available upon request-psychiatric services Resident #1A was admitted to the facility in April 2023 with diagnoses including dysphagia and feeding by Gastrostomy tube (G-tube). A review of a Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. During an observation 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 observations, policy review and interviews, the facility failed to ensure medications were stored securely in the resident care unit affecting 4 Residents (#65, #170, #268 and #273). Findings Include: Review of facility policy titled 'Medication Storage,Security, and Access' Revised 5/1/2023, Indicated the following: Policy: All medications will be stored and secured in accordance with all State and Federal regulations. Definition: *Secure Area: A secure area is an area in which drugs and biologicals are stored in a manner to prevent unmonitored access by authorized individuals. Procedure: Medications stored in patient care areas: *2. All medications are stored in a secured location or in an area where medication storage area is under continuous surveillance by licensed personnel. The Director of Pharmacy has authority to designate storage areas for all medications. Patient's own medication storage: Patient's own medication that cannot be sent home with a family member must be secured in a tamper evident bag and stored in the pharmacy department until discharge. During…

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.