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Deficiency Records for Levindale Hebrew Ger Ctr and Hsp
A list of the most recent deficiencies for Levindale Hebrew Ger Ctr and Hsp. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Levindale Hebrew Ger Ctr and Hsp. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-11-19 | 2025-01-17 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2024-11-19 | 2025-01-17 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-11-19 | 2025-01-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-11-19 | 2025-01-17 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-11-19 | 2025-01-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-11-19 | 2025-01-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-11-19 | 2025-01-17 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-11-19 | 2025-01-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-11-19 | 2025-01-17 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-11-19 | 2025-01-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-11-19 | 2025-01-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-11-19 | 2025-01-17 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-11-19 | 2025-01-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-11-19 | 2025-01-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-11-19 | 2025-01-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-11-19 | 2025-01-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-11-19 | 2025-01-17 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-11-19 | 2025-01-17 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-11-19 | 2025-01-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-11-19 | 2025-01-17 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2024-11-19 | 2025-01-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-11-19 | 2025-01-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-11-19 | 2025-01-17 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-11-19 | 2025-01-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-11-19 | 2025-01-17 | N |
| Provide activities to meet all resident's needs. | Health | 2024-11-19 | 2025-01-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-11-19 | 2025-01-17 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-11-26 | 2025-01-02 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-11-26 | 2025-01-02 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-11-26 | 2025-01-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-11-26 | 2025-01-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-11-26 | 2025-01-02 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-11-26 | 2025-01-02 | N |
| Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2024-11-26 | 2025-01-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-11-26 | 2025-01-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-08 | 2023-07-14 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-08 | 2023-07-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-08 | 2023-07-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-08 | 2023-07-14 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-08 | 2023-07-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-08 | 2023-07-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-08 | 2023-07-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-08 | 2023-07-14 | Y |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2020-01-10 | 2020-02-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-10 | 2020-02-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-20 | 2020-01-17 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-11-20 | 2020-01-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-20 | 2020-01-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-20 | 2020-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-20 | 2020-01-17 | N |
| Keep all essential equipment working safely. | Health | 2019-11-20 | 2020-01-17 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-08-08 | 2018-08-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-08 | 2018-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-08 | 2018-08-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-08 | 2018-08-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-25 | 2018-08-29 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-06-25 | 2018-08-29 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-06-25 | 2018-08-29 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-06-25 | 2018-08-29 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-06-25 | 2018-08-29 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-06-25 | 2018-08-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-06-25 | 2018-08-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-06-25 | 2018-08-29 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-06-25 | 2018-08-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-25 | 2018-08-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-25 | 2018-08-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-25 | 2018-08-29 | N |
| Provide appropriate foot care. | Health | 2018-06-25 | 2018-08-29 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-06-25 | 2018-08-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-06-25 | 2018-08-29 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-06-25 | 2018-08-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-25 | 2018-08-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-06-25 | 2018-08-29 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2018-06-25 | 2018-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-25 | 2018-08-29 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2018-06-25 | 2018-08-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-06-25 | 2018-08-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-06-25 | 2018-08-29 | N |
| Post nurse staffing information every day. | Health | 2018-06-25 | 2018-08-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-06-25 | 2018-08-29 | N |
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