Levindale Hebrew Ger CTR & HSP

In the surveyor’s words

From the most serious findings on record at Levindale Hebrew Ger CTR & HSP, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 18, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF684Nov 18, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF609Nov 19, 2024

  Based 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. The findings include: 1a) On 11/4/2024 at 9:45 AM the surveyor reviewed the facility investigation file for the facility reported incident (FRI) #MD00200402 for Resident #11. Review of the facility investigation file revealed that Resident #11 sustained a fracture of the right hip, and the facility Director of Nursing (DON) reported the fracture as an injury of unknown origin on the initial report form that was submitted to the Office of Healthcare Quality (OHCQ) on 12/8/2023 at 14:30 PM (2:30 PM). […]

• No harm, potential for more than minimal, patternF641Nov 19, 2024

  Based 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. The findings include: The Minimum Data Set (MDS) is a health status screening and assessment tool used for all Residents of long-term care nursing facilities. The MDS is part of the federally mandated process for clinical assessment of all Residents in Medicare and Medicaid certified nursing homes. […]

• No harm, potential for more than minimal, patternF550Jun 8, 2023

  Based on observation and interview, it was determined that the facility staff failed to promote care for residents in a manner and in an environment that maintained or enhanced the resident's dignity and respect. This was evident for 6 (#20, #21, #22, #23, #24, #25) of 25 residents reviewed during a complaint survey. The findings include: A urinary drainage bag collects urine through a tube that is inserted into the bladder. On 6/5/23 at 8:32 AM observation was made of Resident #20. There was a urinary bag hanging on the right side of the bed with the contents visible from the hallway. A second observation was made on 6/6/23 at 12:01 PM of the same urinary bag hanging off the side of the bed. […]