Julian J Levitt Family Nursing Home

Inspectors wroteBased on interviews, and record reviews, the facility failed to implement a system of surveillance for infection tracking, placing residents at risk for inadequate infection monitoring and spread of infections. Specifically, the facility failed to: -Maintain an up-to-date infection line listing for tracking incidents of infection in the facility when the facility's Infection Prevention and Control Plan indicated an up-to-date infection line listing would be maintained. -Include required information on the infection line listing for infection monitoring and tracking.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure personal care was provided with respect and dignity, in a manner to maintain and enhance quality of life for one Resident (#539) out of a total sample of 36 residents. Specifically, the facility failed to: -Ensure that Resident #539 was covered/clothed as requested by the Resident when during personal care, staff left the Resident exposed and uncovered in his/her bed, when the Resident required assistance from staff for personal care, resulting in the Resident feeling disrespected and dehumanized. -Ensure a timely response to Resident #539's undignified experience which increased the Resident's risk for further undignified experiences at the facility.

Inspectors wroteBased on record review, and interview, the facility failed to refer one Resident (#77) for a Preadmission Screening and Resident Review (PASRR- a federal and state-required process that is designed to, among other things, identify evidence of serious mental illness [SMI] and/or intellectual or developmental disabilities [ID/DD] in all individuals [regardless of source of payment] seeking admission to Medicaid-or Medicare-certified nursing facilities) Level II Evaluation (an evaluation conducted to determine if an individual with a newly evident or possible SMI, ID, or a related condition for Level II resident review upon a significant change in status assessment) out of a total sample of 36 residents. Specifically, for Resident #77, the facility failed to refer the Resident for a Level II PASRR Evaluation after receiving a new diagnosis of Psychosis.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one Resident (#52) received treatment and care in accordance with professional standards of practice, out of total sample of 36 residents. Specifically, for Resident #52, the facility failed to follow-up with a recommendation made by the Ophthalmologist to increase the use of Refresh Optive Ophthalmic (a preservative-free eye drop designed to relieve dry eye symptoms) from two times per day to four times per day.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to provide treatment for hearing loss for one Resident (#121), out of a total sample of 36 residents. Specifically, the facility failed to ensure recommendations made from the Audiologist (professional that specializes in diagnosing, treating, and managing hearing loss and balance disorders) were implemented for Resident #121 in order to improve his/her hearing ability.

Inspectors wroteBased on records review, and interviews, the facility failed to obtain laboratory services as ordered by the Physician for one Resident (#143) of five applicable residents, out of a total sample of 36 residents. Specifically, the facility failed to obtain laboratory services as ordered by the Physician, to check Resident #143's Keppra (Levetiracetam: medication used to manage seizures) level, placing the Resident at risk for inadequate medication monitoring and complications related to medication use.

Inspectors wroteBased on interviews, and record reviews, the facility failed to maintain complete and accurate clinical records for three Residents (#155, #533, and #423) out of a total sample of 36 residents. Specifically, 1. For Resident #155, the facility failed to record the Resident's post void residual (PVR: amount of urine remaining in the bladder after one urinates) when PVRs were ordered to monitor the Resident's Kidney Disease, placing the Resident at risk for inadequate monitoring of his/her medical condition. 2. For Resident # 533, the facility failed to document the administration of a newly ordered dose of Lasix (diuretic medication that helps reduce fluid buildup in the body), when the Resident experienced symptoms of Congestive Heart Failure (CHF: [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a Hoyer lift (mechanical mobility aid that supports a person's body weight to allow movement from one surface to another), the Facility failed to ensure his/her environment was as free of incidents/accidents as possible, when on 11/19/24, Certified Nurse Aide (CNA) #3 and CNA #4, who had set up and prepared him/her for transfer out of bed, did not properly set up (position of the legs/base) the Hoyer lift, as they transferred Resident #1 the lift started to tip over sideways, Resident #1 was lowered to the floor by staff during the incident, and the Hoyer lift completely tipped over landing on the floor next to the resident.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who's comprehensive care plan indicated he/she required assistance of two staff members for bed mobility, the Facility failed to ensure staff implemented and followed interventions in his/her care plan, when on 04/28/24 Certified Nurse Aide (CNA) #1 provided care to Resident #1, who was in bed, without another staff member present to assist her. CNA #1 rolled Resident #1 on his/her side, away from her, Resident #1 rolled off the bed, fell onto the floor, landing on his/her right side and immediately complained of pain. Resident #1 was transferred to the Hospital Emergency Department (ED) and diagnosed with acute non-displaced (stable) fractures of the right superior and inferior pubic rami (group of bones that make up the pelvis).

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who required assistance of two staff members for bed mobility, the Facility failed to ensure he/she was provided with the necessary level of staff assistance and required assistive device (bilateral side rails) to maintain his/her safety and prevent an incident/accident resulting in an injury, when on 04/28/24 during the provision of care, Certified Nurse Aide (CNA) #1, who had not gotten another staff member to assist her, put the side rails down, rolled Resident #1 on to his/her side in bed, Resident #1 rolled off the bed onto the floor, landing on his/her right side and immediately complained of pain. [...]

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who were severely cognitively impaired, the Facility failed to ensure Resident #1 and Resident #2's right to personal privacy was respected, when on 03/14/24, Certified Nurse Aide (CNA) #1 used her personal cell phone to participate in a non-work related, live video call, while providing care to Resident #1 and Resident #2, without the consent of the residents or their representatives.

Inspectors wroteBased on interview and record review the facility failed to ensure accurate medical records were maintained for five Residents (#21, #141, #78, and #262) out of a total sample of 35 residents. Specifically, the facility staff failed to: 1. For Resident #21, ensure Physician's orders accurately indicated the process for maintaining the Resident's enteral nutrition (a form of nutrition delivered into the digestive system as a liquid/ also referred to as tube feed) on dialysis (treatment used to treat end stage renal disease[ESRD]) days and the Resident's total amount of enteral nutrition formula consumed daily was documented each shift as ordered. 2. [...]

Inspectors wrote1b. On 2/14/24 at 12:15 P.M., during an observation on C2 Unit, the surveyor observed CNA #9 enter a resident room with an Isolation Precaution sign hung outside the door. CNA #9 entered the resident room without first donning any eye protection. The surveyor observed that CNA #9 was not wearing any eye protection when exiting the Isolation Precaution room at 12:20 P.M. During an interview at the time, CNA #9 said the resident in the isolation room was positive for COVID-19, and that he should have donned eye protection prior to entering the isolation room. During an interview on 2/14/24 at 2:10 P.M., UM #2 said when staff entered a room where a resident was under isolation precautions for COVID-19, the staff must first don a gown, an N-95 mask, gloves and eye protection. UM #2 further said that CNA #9 should have worn eye protection when he entered the isolation room. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide care and services to accommodate the needs of one Resident (#128) out of a total sample of 35 residents. Specifically, for Resident #128 who was ordered for 15-minute safety checks, the facility staff failed to respond to a call light in a timely manner to provide assistance with repositioning, personal care and meal assistance.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to ensure that baseline care plans were developed for two Residents (#261 and #262) out of total sample of 35 residents. Specifically, the facility failed to: 1. For Resident #261, develop a baseline care plan relative to communication within 48-hours for Resident #261 who was nonverbal. 2. For Resident #262, develop a baseline care plan that included Physician orders for care and services relative to Oxygen (O2) use and laryngectomy care within 48-hours of admission.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a plan of care was implemented for one Resident (#128) out of a total sample of 35 residents. Specifically, the facility staff failed to: 1. Conduct safety checks every 15 minutes, per Physician's order. 2. Assist the Resident with his/her breakfast meal per his/her plan of care.

Inspectors wroteBased on interviews and record review the facility failed to ensure an audiology (hearing services) appointment was arranged for one Resident (#123) out of a total sample of 35 residents. Specifically, the facility staff failed to ensure that Resident #123, who had diagnosed hearing loss was provided with audiology services as required.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure that medications were appropriately secured on two Units (A1 and [NAME] 1) out of five units observed. Specifically, the facility staff failed to ensure that unattended medication storage carts were securely locked and not accessible to residents, staff and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) Assessments were completed accurately for two Residents (#125 and #159) out of a total sample of 35 residents. Specifically, the facility staff failed to accurately reflect on the MDS Assessment: 1. For Resident #125, that the correct weight was entered on the Annual MDS. 2. For Resident #159, an accurate discharge status when completing an unplanned discharge MDS Assessment.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that its staff implemented the plan of care for one sampled Resident (#108), out of a total sample of 30 residents. Specifically, the facility staff failed to apply leg protectors for visible skin tears and bruises on Resident #108's lower extremities, putting him/ her at risk for further injury.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the clinical record relative to advanced directives (written statement of a person's wishes for medical treatment if the person is unable to communicate them) was accurately completed by its staff for one sampled Resident (#60), out of a total sample of 30 residents.