Levindale Hebrew Ger Ctr & Hsp

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure allegations of abuse were timely reported. This was evident for 1(#211) out of 1 Resident reviewed for timely reporting of abuse allegations during the facility's recertification survey.

Inspectors wroteBased on review of Facility Reported Incident (FRI) #329725 and #329731, resident medical records, and other pertinent documentation, interviews with staff, and observations, it was determined that the facility failed to prevent a cognitively impaired resident with known exit seeking/elopement behaviors from exiting the facility on two occasions. This was evident for 1 (Resident #7) out of 16 residents reviewed for wandering/elopement during the complaint survey. This failure resulted in an Immediate Jeopardy for Resident #7. The facility implemented effective and thorough corrective measures following this incident. The facility's plan and actions were verified during this survey, therefore this deficiency will be cited as past noncompliance. The date of correction was 6/17/2025.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to : 1.) ensure residents had physician orders for placement of a WanderGuard device (sensor bracelet) and facility staff were checking the WanderGuards for function. This was evident for 3 (Resident #17, #18, and #19) out of 16 residents reviewed for wandering/elopement; 2.) ensure adequate supervision and monitoring for a resident with documented wandering behaviors and an identified high wander risk, and ensure significant changes in vital signs were recognized, reported, and acted upon. This was evident for 1 (Resident #5) of 2 residents reviewed; 3.) ensure the resident received timely necessary care in response to a resident's change of condition (Resident #4); [...]

Inspectors wroteBased on observations, review of resident medical records, and interviews, it was determined that the facility failed to ensure that residents' rights to a dignified existence were preserved. This was evident for 3 (Resident #1, #12, and #10) out of 22 residents observed during the complaint survey.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed: 1.) to identify all surrogate decision makers and follow professional standards for surrogate decision making, 2.) to ensure all social work actions taken were documented as part of the resident's medical record, and 3.) to ensure supervision of the work of the Social Work Designee. This was evident for 1 out of 2 Residents (Resident #) reviewed for advanced directives complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure an allegation of abuse was reported immediately, but not later than two hours, to the State Survey Agency. This deficient practice was evident for 1 of 5 facility reported incidents reviewed.

Inspectors wroteBased on review of a Facility Reported Incident (FRI), record review, and interview with staff, it was determined that the facility failed to maintain documentation of a thorough investigation. This was evident for 1(#329731) out of 5 FRI's reviewed during the complaint survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to develop and implement a person-centered care plan for a resident who has eloped. This was evident for 1 (Resident #7) out of 16 residents reviewed for wandering/elopement during the complaint survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to revise the care plan to meet the needs of a resident identified as a high wander risk. This is evident for 1 (Resident #5) of 16 residents reviewed for wander/elopement risk.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure safe storage of medications. This was evident during the surveyor's initial tour of the facility for 1 medication cart on 1 out of 10 nursing units during the facility's complaint survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards and practices related to residents wander risk status and required assessments. This was evident for 2 (Resident #5 and Resident #7) out of 16 residents reviewed for wandering/elopement during the complaint survey.

Inspectors wroteBased on facility staff interview and medical record review, it was determined that the facility failed to accurately document Resident assessments on the Minimum Data Set (MDS) assessment as evidenced by inaccurate coding for Residents. This was found to be evident for 4 (Resident #191, #11, #164 and #40) out of 73 Residents reviewed on the survey.

Inspectors wroteBased on review of the facility's investigation file, review of medical records and interviews, it was determined that the facility failed to honor and respect a resident's wishes for Activities of Daily Living (ADL) cares. This was found evident in 1 (Resident #77) of 3 residents reviewed for Resident rights.

Inspectors wroteBased on record review, and interviews it was determined that the facility failed to notify the Resident's health care Responsible Party (RP) of a change to the Resident's plan of care and the facility failed to provide a Resident's Representative/guardian the right to be involved in the care planning process. This was found evident in 2 (Resident #51 and #40) of 3 Residents reviewed for resident rights.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to maintain a proper resident's Advance Directives in the Resident's medical record and/or offer to formulate one. This was found to be evident for 2 (Residents #32 and #49) out of 7 residents reviewed for the Advance Directives during the annual survey.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to inform the Resident's primary care physician of the need to alter treatment. This was found evident of 1 (Resident #51) of 2 residents reviewed for change of condition.

Inspectors wroteBased on review of the facility's investigation report, record review, and interviews, it was determined that the facility failed to protect a resident from being physically restrained by an employee. This was found evident on 1 (Resident #77) of 7 Residents reviewed for abuse.

Inspectors wroteBased on facility staff interview and medical record review it was determined that the facility failed to provide notification to the Ombudsman of the residents that transferred to the hospital. This was found to be evident in 2 (#191 & #30) out of 3 residents reviewed for hospitalizations.

Inspectors wroteBased on medical record review, and interviews it was determined the facility failed to provide the Resident and/or Representative with a written notice of the facility's bed hold policy upon transfer to an acute care facility. This was evident for 1 (Resident #21) of 3 residents reviewed for hospitalization.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to implement interventions in a care plan. This was evident for 1 (Resident #224) of 13 residents reviewed for care plans.

Inspectors wroteBased on interview and record review it was determined that the facility staff failed to ensure a resident's right to participate in the resident-centered care plan meeting and failed to conduct care plan meetings after each resident Minimum Data Set (MDS) assessment. This was found evident in 2 (Resident #147 & #51) out of 13 Residents reviewed for care planning.

Inspectors wroteBased on interviews and record review it was determined that the facility failed to have an activities program designed to meet the interests and needs of Residents based on the Residents comprehensive assessment and care plan. This was found evident of 1 (Resident #40) of 4 residents reviewed for activity during an annual survey.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to provide treatments according to a Resident's plan of care. This was found evident of 1 (Resident #77) out of 2 residents reviewed for skin care.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to ensure a Resident in need of hearing aides received services to obtain replacement hearing aides. This was found evident of 1 (Resident #105) of 2 residents reviewed for hearing and vision.

Inspectors wroteBased on observation, record review, and interviews it was determined that the facility failed to provide treatment to prevent further decreased range of motion for a Resident. This was found evident of 1 (Resident #40) out of 5 residents reviewed for mobility.

Inspectors wroteBased on review of medical records and interviews it was determined that the facility failed to adequately supervise and assist a dependent resident during Activity of Daily Living (ADL) care. This was found evident for 1 (Resident #121) out of 9 residents reviewed for accidents.

Inspectors wroteBased on observation, record review and interview it was determined that the facility staff failed to follow appropriate tube feeding treatment and gastrostomy tube (G-tube) site care. This was evident for 1 (Resident #36) out of 2 residents reviewed for tube feeding treatment during the annual survey.

Inspectors wroteBased on observation, record review, and interview with facility staff, it was determined that the facility failed to obtain a bed rail assessments and documentation that informed consent was obtained prior to the use of the bed rails. This was evident of 1 (Resident #141) residents reviewed for accidents.

Inspectors wroteBased on observations, reviews, and interviews it was determined that the facility failed to provide necessary behavioral health services according to the identified individual need in the plan of care. This was found evident of 3 (Resident #105, #245 & #214) 3 residents reviewed for behavioral health services.

Inspectors wroteBased on record review and staff interview, it can be determined that the provider failed to follow through with a pharmacist's recommendation after a medication regimen review. This was evident for 1 (Resident #92) of 5 resident's reviewed for unnecessary medications.

Inspectors wroteBased on interviews and record review it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices. This was found evident in 3 (Resident #140, #33 and #72) out of 73 residents reviewed during the survey.

Inspectors wroteBased on facility staff interviews and closed record reviews it was determined that the facility failed to report alleged violations of abuse as required. This was found to be evident in 5 (Resident #11, #217, #195 & #39 & #147) out of 13 Residents reviewed for reporting of alleged violations.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to protect the residents' private space from unauthorized photographs and recordings. This was evident for 1 (Household 5) out of 10 units.

Inspectors wroteBased on observation, review of the facility's investigation report, record review, and interviews, it was determined that the facility failed to protect a resident from physical and verbal abuse. This was found evident of 2 (Resident #201 & #53) of 7 Residents reviewed for abuse.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to maintain pertinent documentation of a reported investigation. This was evident for 1 (Resident #197) of 24 facility reported incidents.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to adequately evaluate the effectiveness of pain medication for a resident. This was evident for 1 (Resident #22) out of 14 residents reviewed for pain management.

Inspectors wroteBased on review of the facility's investigation report, record review, and interviews, it was determined that the facility failed to provide a resident with an employee that practiced the appropriate skill set according to their education. This was found evident on 1 (Resident #201) of 7 Residents reviewed for abuse.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to protect a resident from significant medication errors by inaccurately ordering medications on admission. This was evident for 1 (Resident #197) of 5 residents reviewed for medications.

Inspectors wroteBased on medical record review and interview with the Director of Nursing (DON) the facility failed to notify the responsible party in writing of the transfer to hospital. This was evident for 2 out of 2 residents (Resident #188 and Resident #160) investigated for hospital transfer.

Inspectors wroteBased on review of medical record and interview with facility staff, it was determined that the facility failed to ensure that residents receiving insulin had physician prescribed parameters and that those parameters were followed. This was evident for 1 of 4 residents (Resident #163) reviewed for receiving insulin.

Inspectors wroteBased on medical record review and interview, the facility failed to reorder Ativan 0.5 mg PRN (as needed) after 14 days. This was evident for 1 out of 4 residents (Resident #143) reviewed for psychotropic medications.

Inspectors wroteBased on observation, the facility staff 1) on household #6 failed to properly wash their hands prior to the lunch service. This was evident for 4 out of 5 employees (Staff # 4, #5, #6, #7) observed on one of six households during observations made during the survey and 2) the facility failed to ensure that linen was transported in a sanitary manner. This was observed on one of nine units during observations made during the survey. The Findings Include: 1. On 11/19/19 during the 12:00 lunch service on Household #6 was observed. The following staff washed their hands incorrectly: Staff #4 washed their hands with water and turned off the faucet with bare hands and not with a clean towel (2 times). Transferring germs from the faucet to the clean towels to the hands. [...]

Inspectors wroteBased on observation and staff interview the facility staff failed to maintain kitchen equipment in an operating condition. This was evident for 1 out of 6 satellite kitchens observed during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to ensure Resident #6 had a Minimum Data Set (MDS) assessment review completed in a timely manner. This was evident for 1 of 7 residents reviewed for timeliness of MDS reports during the survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that the residents and the resident's representatives were provided written notification of the transfer and the reason for the transfer to the hospital. This was found to be evident for 4 out of 5 residents (#149, #94, #346 and #122) reviewed for hospitalization during the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to: 1) assess the resident's Activities of daily living (ADL), 2) assess the resident's bowel and bladder status, 3) assess the resident's skin condition and 4) assess the resident's health condition. This was found to be evident for 2 of 5 residents (Resident #346 and #94) reviewed during the investigative stage of the survey.

Inspectors wroteBased on observation, interview and review of water temperature logs it was determined that the facility failed to 1. have a system in place to address potentially dangerously high water temperatures on two out of the ten units of the facility. Additionally, it was determined the nursing staff failed to properly administer and secure medications left for residents to self-administer (Resident #446 and #118). This was evident for 2 of 5 residents selected for accident hazard investigative review.

Inspectors wroteBased on review of employee files and interview it was determined that the facility failed to have an effective system in place to ensure skills competencies were demonstrated by newly hired nurses and geriatric nursing assistants (GNA). This was found to be evident for 1 of 3 newly hired nurses (Nurse #20) and 2 out of 3 newly hired GNAs (GNA #26 and #27) reviewed for staffing during the investigative portion of the survey and has the potential to affect all residents.

Inspectors wroteBased on review of employee files and interview it was determined that the facility failed to perform annual performance reviews for the geriatric nursing assistants (GNA). This was found to be evident for 3 out of 3 GNAs (#21, #22, #23) reviewed for regular in-service training.

Inspectors wroteBased on review of staffing sheets it was determined that the facility failed to ensure required information was included on the daily posted staffing. This was found to be evident for all ten of the units in the facility.

Inspectors wroteBased on medical record review and interviews with facility staff, it was determined that the facility pharmacist failed to recognize and report the lack of indications for use of ordered medications for 5 of 9 residents reviewed for unnecessary medications (#129, #137, #148, #25 and #88).

Inspectors wroteBased on record review and interview, it was determined that the facility staff failed to ensure that medication regimens were free from unnecessary medications. This is evident for 6 of 9 residents (#129, #98, #137, #148, #25, and #88) selected for review of unnecessary medications.

Inspectors wroteBased on observation record review and staff interview it was determined that the facility staff failed to follow proper food handling practices to prevent the outbreak of foodborne illness. The deficient practices have the potential to affect all residents in the facility

Inspectors wroteBased on family interview, observation, record review and staff interview it was determined that the facility staff failed to include the Responsible Party (RP) in the provision of care for a resident. This was true for 1 of 3 (#179) residents reviewed for care planning during the survey.

Inspectors wroteBased on interviews of residents and staff and a review of facility documents it was determined the facility failed to provide reasonable accommodations for residents and ensure that the showers on the unit were functioning properly and that safe temperatures were maintained. This was found to be evident for 1 unit (Hall 2) after a resident council meeting was conducted during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on review of resident council meeting minutes and interview with residents and facility staff, it was determined the facility failed to give adequate responses to grievances that was presented by the resident council. This was found to be evident during a resident council meeting, and a review of the resident council meeting minutes that was completed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on interviews with residents and facility staff it was determined the facility failed to deliver mail to residents unopened on Saturdays. This was found to be evident after a resident council meeting was conducted during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review, and interview with staff it was determined that the facility staff failed to ensure 1) the appropriate Responsible Person was identified and consulted to complete the Medical Order for Life-Sustaining Treatment (MOLST) and 2) the process in determining a resident's decision making capacity and certification regarding medical ineffectiveness of treatment was completed timely. This was evident for 1 of 4 (#94) residents reviewed during the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to 1) notify the responsible party of a change in the resident's condition This was found to be evident for 1 out of 4 residents (#94) reviewed during the investigation stage of the survey.

Inspectors wroteBased on medication cart observations and staff interviews it was determined the facility staff failed to ensure medical record was kept in confidential manner. This was evident in 1 out of 2 medication carts.

Inspectors wroteBased on observation and staff interviews during an environmental tour, it was determined that the facility staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 1 out of 10 nursing care units

Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to develop comprehensive care plans as evidenced by failure to develop care plans to 1. address the use of a CPAP machine, 2. the use of a Foley catheter and 3. need for oxygen. This was found to be evident for 1 of 38 residents (#149) reviewed during the investigative portion of the survey.

Inspectors wroteBased on observation, record review, Resident Representative (RP) and staff interview, it was determined that the facility staff failed to provide routine foot treatment to prevent complications from conditions such as diabetes or immobility. This was found to be true in 1 (Resident #179) of 10 residents reviewed during the initial pool phase of the survey.

Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to 1. ensure the use of a physician ordered treatment for obstructed sleep apnea, 2. ensure a residents respiratory status was monitored as ordered, and 3. inform the physician of continued use of oxygen that had been ordered for use as needed. This was found to be evident for two out of four residents (#149 and #252) reviewed for respiratory care during the investigative portion of the survey.

Inspectors wroteBased on medical records review and interview with staff it was determined that the facility failed to obtain a radiology test in a timely manner causing a potential delay in treatment. This was evident for 1 out of 4 residents (Resident #94) reviewed during the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form for a Resident (#446). This was evident for 1 of 35 residents reviewed for advanced directives.

Inspectors wroteBased on observation and staff interview it was determined that facility staff failed to follow transmission-based precautions while providing care to residents. This was true in for 1 of 19 residents (#179) observed during the initial screening process of the survey. This deficient practice however has the potential to affect all the residents on the unit.

Inspectors wroteBased on resident and staff interviews and review of facility pest control logs it was determined the facility failed to keep resident's environment safe and free of pests and rodents. This was found to be evident after a resident council meeting was conducted during the facility's annual Medicare/Medicaid survey and had the potential to affect all residents.

Inspectors wroteBased on review of the facility assessment it was determined that it failed to include information in regard to the number and qualifications of staff that the facility employs or the number of staff that are needed to provide care for the resident population. This has the potential to affect all residents and was identified during the staffing review.