United Hebrew Geriatric Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, and observations conducted during an abbreviated (2968858) survey, the facility did not ensure that a resident was free from abuse. This was evident for 1 (Resident #1) of 3 residents sampled for abuse. Specifically, Certified Nursing Assistant #1 is seen in video footage dated 03/26/2026 hitting the back of Resident #1's head.The facility policy #276 for abuse prevention last reviewed January 2025 documented that it was their policy to ensure all residents were free from abuse, neglect, misappropriation of resident property and exploitation. Resident #1 was admitted [DATE] with diagnoses which included unspecified dementia, unspecified severity, with other behavioral disturbance. An admission minimum data set (an assessment tool) dated 11/27/2025 documented the resident had a brief interview of mental status score of 4, indicating severe cognitive impairment. Resident #1 had behaviors of wandering and rejection of care that occur 1 (one) to 3 (three) days and impairment 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, record review, and interviews conducted during an abbreviated survey (2968858), the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and law enforcement) in accordance with State law through established procedures. This was evident in one out of three residents reviewed for abuse (Resident #1). Specifically, an alleged incident of abuse involving Resident #1 was reported to facility staff on 03/26/2026 and the facility did not report the allegation of abuse to the Department of Health or law enforcement until 03/30/2026.Review of the facility's abuse prevention and reporting policy #276 last…

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 interviews during an abbreviated survey (2968858), the facility did not ensure a comprehensive care plan was developed and implemented to maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) residents reviewed for abuse. Specifically, Resident #1 had severe cognitive impairment and was involved in a documented incident on 03/26/2026 where abuse occurred and an abuse care plan was not initiated. Review of the facility policy #2-214 comprehensive person-centered care plan dated 1/2023 documented that a comprehensive person-centered care plan is developed for each resident to include measurable goals, objectives and timeframe to meet the resident's medical, nursing, rehabilitation, psycho-social, cultural and nutritional needs. These needs are identified from the IDC (interdisciplinary care) team assessment.Review of the facility's abuse prevention and reporting policy dated 2/2016 and reviewed/revised 1/2025 documented the interdisciplinary team identifies resident risk factors and plans for…

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 did not ensure a Notice of Medicare Non-Coverage is given by the facility to all Medicare beneficiaries at least two days before the termination of services for one (1) of three (3) residents (Resident #194) reviewed for Beneficiary Notification. Specifically, there was no documented evidence that Resident #194 and/or their representative received and signed a two (2) day Notice of Medicare Non-Coverage before termination of services. The findings include: Resident #194 was admitted with diagnoses including unspecified dementia, atherosclerotic heart disease and unspecified atrial fibrillation. The 09/10/2025 admission Minimum Data Set (an assessment tool) documented Resident #194 had severe cognitive impairment, received 100 minutes of occupational therapy and 130 minutes of physical therapy. The 10/20/2025 Notice of Discharge/Transfer documented Resident #194 would be discharged on 10/24/2025.The Beneficiary Protection Notification Review form documented by the former social worker revealed Resident #194's last covered day 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 and record review the facility did not ensure that drugs and biologicals were maintained in accordance with current professional standards for storage, labeling and expiration dates during review of medication storage on two (2) of four (4) units. Specifically, 1) observation of the fourth-floor medication cart revealed one (1) insulin pen with no open date and one (1) insulin pen with no patient label and no open date. The fifth-floor medication cart revealed two (2) insulin pens which had not been discarded within 28 days after opening as per the manufacture's recommendation, and 2) a physician ordered Trelegy Ellipta (inhaler) was left in Resident #155's room on the bedside table. The findings include: 1) The 8/2020 policy titled Administration Procedures for All Medications documented when opening a multidose container, place the date on the container. During observation on 12/02/2025 at 10:51 AM, the medication cart on unit 4 Skalet revealed one Lantus Solostar insulin pen labeled with Resident # 5's name which had no open date and one Admelog…

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, and record review during the recertification survey from 10/2/23 to 10/6/23, the facility did not ensure that care was provided in a manner that maintained dignity for 1 of 2 residents (Resident #7) reviewed for catheters. Specifically, Resident #7 urinary catheter drainage bag was not concealed to prevent direct observation of urine by others. The findings are: The facility policy, titled, ' environment that preserves dignity, and contributes to a positive self image' documented it is the policy of the facility to ensure and respect each residence, rights to dignity, and contribute to a positive self image, which included to care for a residence in a manner, and in an environment, that promotes maintenance or enhancement of each residence, quality of life. The facilities policy titled, 'Urine drainage bags' did not include documentation related to privacy covers for the urine drainage bag. Resident #7 had diagnoses included urinary retention, benign prostatic hyperplasia, and obstructive and reflux uropathy. The Minimum Data Set (MDS- a 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 interview, and record review during the recertification survey from 10/2/23 to 10/6/23, it was determined the facility did not ensure an ongoing program of activities was provided to meet the needs and interests of, and support the physical, mental, and psychosocial well-being of the residents, based on the comprehensive assessment and care plan for 1 of 2 residents (Resident #18) reviewed for activities. Specifically, Resident #18 voiced concern about the facility's cuts to their activities programming and how it negatively affected their daily quality of life. The findings are: A facility policy titled, 'Therapeutic Recreation Services', last revised 1/2000, documented, It is the policy of this facility to provide activities that are multi-faceted and reflect each individual resident's needs. Resident #18 was admitted to the facility with diagnoses including but not limited to atrial flutter, spinal stenosis, and major depressive disorder. The 7/14/23 Minimum Data Set (MDS- a resident assessment tool), documented Resident #18 had a Brief Interview of Mental Status of 15…

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 during a recertification survey from 10/2/23 to 10/6/23, the facility did not ensure food was served under sanitary conditions for 2 of 12 residents (Residents #335 and #126) . Specifically, registered nurse (RN) #1 did not perform hand hygiene between serving residents while passing out food during a breakfast meal to prevent cross contamination and infection and was wearing gloves to serve meals. Findings include: The facility Hand Hygiene policy revised 9/28/18 documents hand hygiene is the single most effective action in the prevention of transmission of infection. Careful hand hygiene must be performed before and after any direct resident care. During an observation on 10/02/23 at 8:23 AM, RN#1 passed breakfast meal trays to residents on the 2nd floor dining room while wearing gloves. RN#1 took a tray and with gloves on their hands delivered it to Resident #335. While still wearing the same gloves, RN#1 returned to the food supply room next to the serving station and touched the keypad with the gloved finger to place a code to…

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, record review and interview during the recertification survey (10/2/23-10/6/23) the facility did not ensure that staff maintained 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. Specifically, two Certified Nurse Aides (CNAs) were observed not using Personal Protective Equipment (PPE) while assisting a resident that was on contact precautions and when CNAs exited the resident room, did not perform proper hand hygiene. The findings are: The Facility policy for Transmission Based Precautions dated 8/30/2022 documents signage outside the resident's room will be posted to communicate precautions to all healthcare personnel. Signage for Contact Isolation and verbal communication between staff can enhance compliance to minimize transmission of infection. Wear a gown and gloves for all interactions that may involve contact with the resident and their environment. The facility policy for Hand Hygiene dated March 2017…

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 record review and interview conducted during a recertification survey, the facility did not ensure that for 1 of 2 residents (#180) reviewed for hospitalization that the resident or her representative were given timely written notification of the bed hold policy before transfer in a language and manner they could understand. The findings are: Resident #180 was admitted on [DATE]. Her diagnoses include but are not limited to anemia, hypertension, heart failure, macular degeneration and osteoporosis. The Quarterly Minimum Data Set (MDS - a resident assessment and screening tool) dated 12/21/2018 indicated that Resident #180 is cognitively intact. Review of a 3/15/2019 nursing note showed that Resident #180 was transferred to the emergency room and admitted with a diagnosis of multiple fractures resulting from a fall. Resident #180 was subsequently discharged from the hospital and returned to the facility on 3/18/2019. Review of the medical record and interview with the Director of Social Work on 6/13/2019…

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 upon interview and record review conducted during the recertification survey, the facility did not ensure that each resident received proper treatment and assistive devices to maintain hearing ability. This was evident for 1 of 38 residents reviewed. (Residents#109). The findings are: Resident #109 was admitted on [DATE] with diagnoses of Hypertension, Diabetes Mellitus and Chronic Obstructive Pulmonary Disease. The annual MDS (minimum data set-a resident assessment tool) dated 10/23/18 documented the resident was cognitively intact, had minimal difficulty hearing, used a hearing aid or other hearing appliance, made himself understood, and understood others. Subsequent quarterly MDS assessments on 12/22/18, 3/6/19 and 4/14/19 all documented that the resident had minimal difficulty hearing, used a hearing aid or other hearing appliance, made himself understood, and understood others. The comprehensive care plan (CCP) for communication dated 12/10/16 documented the following; resident had adequate hearing…

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.