Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Levindale Hebrew Ger Ctr & Hsp during CMS and state inspections, most recent first.
A resident emailed the CAO describing that the DON and a GNA had yelled at them and explicitly requested that the facility self-report the incidents, including to CMS and the Board of Nursing. The CAO acknowledged the concerns, apologized, and indicated that appropriate action would be taken, but the Administrator later stated that leadership had no knowledge of any abuse concerns until informed by surveyors months later, at which point a report was made to OHCQ. The Administrator, who serves as abuse coordinator, confirmed that all staff must report abuse allegations within two hours and that allegations must be reported even if a resident does not want a grievance filed, yet also acknowledged that the allegation involving the DON had not been recognized or reported until the surveyor pointed to the prior correspondence. This resulted in a failure to timely report and investigate the resident’s abuse allegations involving both the GNA and the DON.
A resident with severe cognitive impairment and documented exit-seeking behavior eloped from a secured unit on two occasions. After a group activity, the resident left through doors near the main entrance, boarded an MTA bus, and was later found at a hospital. On a later occasion, the resident told an LPN/UM they wanted to go for a walk, then was found missing and later located downtown. The record also noted the resident had previously followed staff through a locked door toward the front entrance.
A facility failed to ensure WanderGuard devices had physician orders and were being checked for function, failed to adequately monitor a resident with a high wander risk and abnormal temperatures, failed to provide timely treatment for a resident’s change in condition before hospital transfer, and failed to provide timely incontinence care and call light response. The record also showed a resident’s therapeutic diet plan did not match the medical diet orders used for meal tickets.
Failure to Preserve Resident Dignity: A resident was observed in a soiled incontinent brief with the room door wide open, later being fed by staff standing over the resident while using a cell phone. Two other residents were repeatedly observed in bed with uncovered Foley drainage bags facing open doors and visible from the hallway. Staff acknowledged the dignity concerns, and the DON stated residents should be dressed, receive incontinence care, and be fed with respect.
A resident was found incapable of medical and financial decision making, but the facility did not document attempts to contact the resident’s son even though hospital records listed both adult children and noted the son’s involvement. Staff instead relied on the daughter for medical decision making until a later note stated the sister had been used as surrogate by error. Interviews also showed the SWD’s actions were not fully documented and that supervision of the SWD was unclear, with the DON and SWM acknowledging that documented attempts to determine the correct surrogate were expected.
A facility failed to report an allegation of abuse to the State Survey Agency within the required 2-hour timeframe. Staff became aware of the allegation in the morning, the DON and administrator were notified later that morning, and the initial report to OHCQ was not made until around noon, which was late.
Incomplete Investigation of Resident Elopement: A resident eloped from the unit and facility, but the FRI investigation did not document the circumstances leading up to the event, how the resident exited, or how, when, and where the resident was found. The file contained only limited notes and one unsigned staff statement, with no evidence of additional staff or resident interviews. In interview, the DON and Administrator said camera footage showed a staff member did not ensure doors fully closed, allowing the resident to exit, board an MTA bus, and be found by police, but this information was not included in the investigative record or the resident’s EMR.
Failure to develop and implement a person-centered elopement care plan was identified for a resident with unspecified dementia and behavioral disturbance who had multiple elopement events and an episode of following staff through a locked door toward the front entrance. The care plan listed general elopement precautions such as a wander guard and shift monitoring, but it did not reflect the resident’s actual elopements, identified triggers, enhanced behavioral monitoring, redirection activities, wander risk assessments, or the increased supervision that had been ordered.
Failure to revise the care plan for a resident with a high wander risk score. The resident had documented wandering behaviors and was identified as resistive to care, but the care plan was not updated to include interventions for the increased risk or the need for increased supervision. The DON and NHA confirmed the resident was not on the wander list and that the required quarterly assessment had been overdue; when completed, the resident’s wander risk score was higher.
Unlocked Medication Cart Observed Unattended: During the initial tour, surveyors observed a medication cart on one nursing unit with the lock button protruding outward, indicating it was unlocked, and it was unattended in the resident hallway. Surveyors were able to open all drawers containing various medications. RN #3 confirmed responsibility for the cart when the concern was brought to the nurse's station, and the DON was later informed.
Incomplete wandering risk assessments and inaccurate resident risk documentation were identified for two residents. One resident had a high wander risk score in the EMR but was not on the wander list and lacked a quarterly assessment, while another resident had exit-seeking behavior and an elopement event documented, yet the wandering risk assessments remained incomplete and scored 0 despite required screening expectations.
The facility failed to report alleged abuse and injuries in a timely manner for multiple residents. For one resident, a hip fracture was reported without a follow-up investigation. Another resident's abuse allegation was documented but not reported. A third resident's abuse report was delayed, and two other residents' injuries were reported late, exceeding the required timeline. The DON and NHA acknowledged these reporting failures.
The facility failed to accurately document MDS assessments for multiple residents, including incorrect discharge dates, misreported catheter and continence status, unnoted missing teeth, and inaccurate upper extremity impairment coding. These deficiencies were identified through surveyor interviews and record reviews.
A staff member recorded themselves in a clinical area of Household 5 and posted the video on TikTok, leading to their termination for Gross Misconduct. Although no residents were recorded, the act violated privacy protocols. The DON confirmed the staff had been educated on resident rights and HIPAA.
A facility failed to protect residents from abuse and aggression. One resident, under 1:1 care due to confusion and fall risk, was subjected to rough handling and verbal abuse by a CNA, witnessed by a roommate. Another resident with severe cognitive impairment was pushed by an aggressive resident, resulting in a fall. The aggressive resident had a history of behavioral issues, and interventions were in place, but the incident still occurred.
A facility failed to maintain documentation for an investigation involving a resident sent out for evaluation due to fever, tachycardia, and hypotension. A nurse incorrectly entered medications from the discharge summary, and the resident's hospital course included altered mental status, hypotension, and treatment for possible sepsis. The DON could not provide hospital records due to HIPAA concerns, but the surveyor obtained them directly.
The facility failed to evaluate the effectiveness of pain medication for a resident in a timely manner. A resident was prescribed tramadol for moderate to severe pain, but the effectiveness was assessed 7.5 and 12 hours after administration, contrary to the standard practice of 1 to 2 hours. The DON stated that reevaluation should occur 30 minutes post-administration, highlighting a gap between practice and standard care.
A resident with a high fall risk and confusion was subjected to rough care by a CNA acting outside her scope of practice. The CNA, who was supposed to monitor the resident, was reported to have physically mishandled the resident, leading to her termination. The DON confirmed that the CNA's actions were inappropriate as sitters are not allowed direct hand contact unless certified as a GNA.
A resident with multiple health conditions experienced significant medication errors upon admission due to incorrect medication orders. The facility failed to accurately reconcile medications, leading to discrepancies in dosage, frequency, and type of medication release. These errors were identified after the resident was hospitalized for confusion, tachycardia, and hypotension, with a diagnosis of Sepsis due to a UTI.
The facility failed to notify the responsible parties of two residents about changes in their care plans, resulting in a deficiency in resident rights. A resident's daughter was not informed about a new skin tear, and another resident's co-guardians were not involved in a care plan meeting. The DON confirmed the lack of documentation for these notifications.
The facility failed to maintain proper documentation of Advance Directives for two residents. One resident's MOLST certification indicated Advance Directives were selected, but no document was found. The Director of Social Service did not see the need for separate records, but the DON later provided a copy from the hospital. Another resident, capable of making decisions, had no Advance Directives on file, and it was unclear if they were offered the opportunity to create one.
A facility failed to inform a resident's primary care physician about multiple vomiting episodes and bowel movement irregularities. The resident, with a PEG tube, experienced chronic vomiting and went several days without a bowel movement, but the physician was not notified of these issues. This lack of communication and adherence to bowel management policy led to a deficiency.
The facility failed to notify the Ombudsman of two residents' transfers to the hospital, as required by regulations. One resident was transferred on two occasions, with only one instance being reported, while another resident's transfer was not reported at all. The facility acknowledged these oversights and indicated changes to ensure proper notification in the future.
A facility failed to provide a written notice of its bed hold policy to a resident's legal guardian upon transfer to a hospital. The resident was transferred twice, but there was no documentation that the policy was communicated. The DON confirmed the process involves sending the policy to the hospital and mailing it to the guardian, but there was no evidence this occurred.
The facility failed to include two residents in their care plan meetings. One resident was not invited to participate in their care plan meeting, despite being capable of expressing their needs, and decisions were made without their input. Another resident did not have a care plan meeting following their quarterly MDS assessment, with no documentation provided to confirm it was held.
A facility failed to meet a resident's needs by not providing adequate music-related activities, despite the resident's care plan emphasizing music engagement. The resident, who had a strong interest in music, was offered activities less than weekly, and the facility did not consistently incorporate music into the care plan, despite family requests and the resident's dependency on staff for emotional and social needs.
A facility failed to administer TED hose as ordered for a resident experiencing leg swelling. Despite a Nurse Practitioner's recommendation and an order for TEDs to be applied during the day, there was no documentation in the resident's medical record confirming their use. The Nursing Home Administrator acknowledged that the order did not translate to the Treatment Administration Record, leading to a lack of documentation. Observations showed the resident's feet were swollen, and the resident reported not wearing TEDs for weeks.
A resident with a hearing deficit misplaced their hearing aids, and the facility failed to ensure replacements were obtained. Despite a care plan update and discussions with the resident's brother, the resident remained without hearing aids for over three months. The Treatment Administration Order required staff to check and assist with hearing aids every shift, but notes indicated they were missing multiple times. The resident's brother did not want to pay for replacements, and guest services needed to proceed with obtaining new hearing aids.
A facility failed to provide appropriate splinting care for a resident with contracted hands. Splints were found off in the resident's room, and the family was unclear about their use. A nurse was unaware of a splinting schedule, which is typically provided by therapy. The resident had previously tolerated some splinting but was not reassessed for splinting needs after returning from the hospital, leading to a deficiency in care.
A resident with impaired mobility fell while attempting to transfer to a bedside commode after a GNA left them unattended. The resident's care plan required assistance with toileting, which was not followed, leading to the incident. The DON confirmed the protocol breach.
A resident with a G-tube was not provided appropriate tube feeding treatment and site care. The feeding pump was turned off, but the tubing remained connected without proper labeling or dating. The G-tube site dressing was not changed as ordered, showing signs of oozing drainage. The on-duty nurse failed to label the Nepro container, disconnect the tubing on time, and change the dressing twice daily. These issues were reported to the Nurse Manager and DON.
A facility failed to conduct a bed rail assessment and obtain informed consent for a resident with hemiplegia and muscle weakness. The resident was observed with all bed rails raised, but no documentation of evaluation or consent was found. The NHA confirmed the absence of an assessment, and the facility's clinical engineering did not evaluate entrapment risks. The Specialty Bed Instruction manual emphasized the need for such assessments, which were not performed.
A provider failed to implement a pharmacist's recommendation to discontinue Novolog and check a resident's A1C levels. Despite agreeing to the recommendation, the provider did not update the orders, leaving Novolog active and no A1C lab ordered. The DON confirmed that providers should write orders when agreeing with pharmacist recommendations.
The facility failed to maintain accurate medical records, as evidenced by conflicting bed rotation orders for a resident and discrepancies in code status documentation for two residents. The Director of Nursing acknowledged the error in bed rotation orders, while nursing staff corrected the code status inconsistencies after surveyor intervention.
A resident, assessed as cognitively intact, communicated refusal of ADL care, but a GNA proceeded with the care against the resident's wishes, citing instructions from other staff. The resident resisted by holding the covers tightly, but the GNA attempted to perform the care regardless. The DON confirmed the incident and acknowledged the GNA's failure to respect the resident's rights.
A resident, assessed as cognitively intact, was physically restrained by a GNA during care despite expressing refusal. The GNA, following instructions from other staff, held the resident down to check for incontinence. The incident was confirmed by the resident and acknowledged by the Director of Nursing.
A resident with behavior problems pushed another resident, causing a fall, due to ineffective implementation of a care plan. The resident had previously warned staff about harming wandering residents entering their room. The care plan, which included interventions like increased supervision, was not followed, resulting in the incident.
The facility failed to provide timely behavioral health services to three residents. One resident with dementia and mood disturbances experienced gaps in psychiatric follow-up, while another resident's psychiatric consultation was delayed due to communication issues. A third resident requiring antipsychotic medications also faced a delay in receiving a psychiatric consult. These deficiencies highlight the facility's failure to meet the behavioral health needs of its residents.
Failure to Timely Report and Investigate Resident Abuse Allegations
Penalty
Summary
The facility failed to ensure that allegations of abuse were timely reported to the proper authorities after a resident made specific abuse-related complaints about staff. On 11/17/25 at 3:12 AM, the resident sent an email to the Chief Administrative Officer (CAO) describing that the DON had previously come into the resident’s room and yelled at them, which the resident perceived as unacceptable behavior in what they considered their home. In the same correspondence, the resident alleged that a Geriatric Nursing Assistant (GNA) had also yelled at them, and explicitly requested that the facility self-report, including requests to report the GNA to the Board of Nursing and to self-report to CMS without retaliation. Later that same day, the CAO responded by email, apologizing for what the resident described, stating that culinary leaders were included for one concern, and indicating that they would follow up with leaders on the GNA and that appropriate action would be taken. Despite these explicit allegations and requests, the Administrator reported during interview on 3/11/26 that the facility had no knowledge of the resident’s abuse concerns until surveyor notification on 2/5/26, at which time a self-report was made to the Office of Health Care Quality (OHCQ). The Administrator confirmed that only one initial report on 2/5/26 and one follow-up report on 2/12/26 had been made regarding this resident, and also stated that all staff are responsible for timely reporting of abuse allegations within two hours, even if information does not reach leadership promptly. The CAO told the surveyor that the resident’s care concerns had been handled through normal processes, were investigated, and found unsubstantiated, and acknowledged receiving multiple emails from the resident prior to discharge at the end of November 2025. During interview, the Administrator, who identified as the abuse coordinator, acknowledged that abuse allegations must be reported even if a resident does not want a grievance filed, yet also stated they were unaware of the abuse allegation involving the DON until the surveyor directed them to the 11/17/25 correspondence. This sequence of events shows that the facility did not timely report or investigate the resident’s abuse allegations involving both the GNA and the DON as required.
Failure to Prevent Repeated Elopement by Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent a cognitively impaired resident with known exit-seeking and elopement behaviors from leaving the secured area on two occasions. The resident had diagnoses including dementia with agitation, anxiety, behavioral disturbance, schizoaffective disorder, bipolar type, drug-induced parkinsonism, and epilepsy. The resident was admitted to a secured nursing unit for cognitive impairment and worsening psychosis, was independent with ambulation, and had a BIMS score of 0 indicating severe cognitive impairment. Although an admission wandering risk assessment scored the resident as not a wandering risk, a nursing progress note documented that the resident was busy seeking exit and wanted to go to another floor and go home. On the first incident, after participating in a group activity in the Town Center, the resident exited the facility through doors near the main entrance while activity staff were escorting other residents to their units. Staff discovered the resident missing shortly afterward and initiated searches of the Town Center, the resident’s unit, other household units, and the surrounding area. Campus security, transit authorities, police, and the resident representative were notified. Security review later showed the resident exited the building and boarded an MTA bus, and the resident was later found at a hospital and admitted for observation and evaluation. The resident sustained no injuries. The resident eloped again after a nurse informed the unit manager that the resident wanted to go out for a walk and needed help to get out. Shortly afterward, the resident was found missing from the unit. Staff initiated an elopement alert, searched the unit, stairways, and the entire interior and exterior of the building, and notified 911, police, transit authorities, and the resident representative. The resident was later located downtown and returned to the secured unit. The report also noted a prior behavior note stating the resident had followed staff through a locked door and gone toward the front door before being brought back to the room.
Failure to manage wandering, abnormal vitals, change in condition, incontinence care, and diet orders
Penalty
Summary
The facility failed to ensure that residents wearing WanderGuard devices had physician orders for the devices and that the devices were being checked for function. During review of the wander/elopement risk list and the electronic medical record, Residents #17, #18, and #19 were found to have WanderGuard sensor bracelets in place without physician orders. Staff interviews confirmed the devices were on the residents, and the Administrator later confirmed that the residents did not have orders for the devices at the time of the survey review. The facility also failed to adequately supervise and monitor a resident with a documented wander risk and to recognize and act on abnormal vital signs. Resident #5 had a wander risk score of 13 and documentation showing wandering behavior related to adjustment to the nursing home, but the resident was not included on the facility wander list and the quarterly wander assessment was overdue. The record also showed low temperatures of 35.7 C and 33.6 C on separate occasions without documented recheck, nurse notification, or provider notification. The DON and NHA were unable to state the accepted temperature range, and the DON confirmed that the low temperature was outside the acceptable range. The facility failed to provide timely necessary care in response to a change in condition for Resident #4. The resident had abnormal lab results suggestive of bacterial infection, reported feeling unwell, had pain, blood pressure issues, and decreased appetite, and a chest x-ray showed multifocal patchy nodular opacities/infiltrates. An antibiotic order was entered, but the medication was not administered before the resident was transferred to the hospital. The record also showed an SBAR note directing a STAT dose and ER transfer for possible sepsis, and the CRNP stated the nurse was expected to give the antibiotic on the evening of the order. The facility further failed to ensure necessary incontinence care and timely response to call lights for Residents #8 and #9, and failed to ensure diet interventions matched the medical diet orders for Resident #9. Call bell reports for two rooms showed approximately 32 requests with response times greater than 15 minutes, and residents reported long waits for assistance. Resident #9 was observed in a heavily saturated brief, and staff confirmed the resident had not been changed as expected overnight. Documentation showed only once-per-shift sign-off rather than point-of-care documentation for incontinence care. For Resident #9, the care plan called for a controlled carbohydrate and heart healthy diet, but the diet order history showed periods when the resident received only a heart healthy diet and later a regular diet, while the directions section contained additional diet instructions that did not populate on the meal ticket.
Failure to Preserve Resident Dignity
Penalty
Summary
The facility failed to preserve residents’ rights to a dignified existence for 3 residents observed during the complaint survey. Resident #1 was found sitting in a wheelchair in a room with the door completely open, wearing a soiled incontinent brief with a brown substance smeared on the front and outside of it and a white T-shirt. The resident pointed to the lower extremities and then to pants located by the closet, indicating a desire to be dressed, and stated yes when asked if he/she wanted to be dressed. Resident #1 was later observed lying in bed being fed breakfast by staff #4, who was standing over the resident while talking on a cell phone. The DON and other staff stated that residents are expected to be fed while staff are sitting next to them to provide respect and dignity, and that residents should be dressed and receive incontinence care. Resident #12 and Resident #10 were each observed in bed with Foley drainage bags partially filled with yellow liquid, uncovered, and positioned facing open doors so the bags were visible from the hallway on multiple observations. Staff acknowledged the uncovered Foley bag concern for Resident #10 when it was pointed out, and the administrator was made aware of the dignity concerns.
Failure to Identify Surrogate Decision Maker and Document Social Work Actions
Penalty
Summary
The facility failed to identify all surrogate decision makers and follow professional standards for surrogate decision making for a resident who was determined to be incapable of decision making for medical care and financial decisions. The resident was admitted on 4/4/25 with hospital paperwork that listed contact information for both adult children and noted the son’s involvement in the prior living environment. A decision-making capacity and treatment limitations form dated 4/8/25 documented two medical care provider certifications finding the resident incapable, but the record did not show any documented attempts to contact the son in addition to the daughter. From 4/8/25 until the son’s later involvement, the daughter was the only adult child used by the facility for medical decision making. A social services note dated 4/16/25 documented a care plan meeting with the resident and daughter, and the son was again mentioned, but the social work designee documented only outreach to the daughter regarding decision making and discharge planning. The record contained no documentation that the social work department attempted to contact the son before 7/29/25. A later social services note dated 7/29/25 stated that the social worker explained to the son that the sister had previously been used as surrogate decision maker due to an error, and the son and daughter verbally acknowledged and understood. The report also identified that social work actions were not fully documented and that supervision of the Social Work Designee was inadequate. The Social Work Manager stated there were no social work consultants and no one else overseeing social work, while the Social Work Designee stated the manager was covering residents on the hall because of differences. During interviews, the DON and Social Work Manager confirmed that documented attempts were expected to determine whether an incapacitated resident had family members for correct surrogacy, and they acknowledged that the Social Work Designee should have adequate supervision for the steps taken when providing social work support. The Manager of Patient Experience also stated that staff had been speaking with the daughter because she was listed as the person to contact, and the son was not initially known to staff.
Late Reporting of Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported immediately, and no later than two hours, to the State Survey Agency. Record review showed staff were notified of the allegation of abuse at 8:40 AM on 8/15/25, and the administrator was notified at 9:54 AM that same morning. The initial report to the Office of Health Care Quality was documented as being made at approximately 12 PM, which was more than two hours after staff first became aware of the allegation. During interview, the DON was informed that the allegation had not been reported within the required two-hour timeframe and later confirmed that the report had been submitted late.
Incomplete Investigation of Resident Elopement
Penalty
Summary
The facility failed to maintain documentation of a thorough investigation for a Facility Reported Incident involving a resident who eloped from the unit and facility. The investigative file for the incident stated only that the resident left the facility and was found shortly after, but it did not include the circumstances leading up to the elopement, how the facility determined how the resident exited, or how, when, and where the resident was found. The file also contained limited corrective documentation, and the resident’s electronic medical record did not document how the resident was able to exit the unit and facility. During review of the incident file, the surveyor found only one unsigned staff statement that did not identify the staff member’s title, along with a nurse’s note and a behavioral note describing the event. There was no evidence of additional staff interviews, and no evidence of an interview with the resident or any other resident on the unit. In interview, the DON and Administrator stated that camera footage showed the resident exiting after a staff member did not ensure the doors were fully closed, then proceeding to the elevators, exiting through the main entrance area, boarding an MTA bus downtown, and being found by police. This information was not included in the investigative file or the resident’s medical record.
Failure to Develop a Person-Centered Elopement Care Plan
Penalty
Summary
Failure to develop and implement a person-centered care plan for a resident with a history of elopement was identified during the complaint survey. Record review and staff interview showed that Resident #7 eloped from the facility on 3/6/2025 at 3:04 PM and again on 6/17/2025 at approximately 3:55 PM. The resident also had a behavior note dated 5/2/2025 documenting that the resident followed a staff member through a locked door, went down the elevator toward the front door, was returned to the room, assessed as within normal limits, and was told not to sit by the door. The resident had a diagnosis of unspecified dementia with other behavioral disturbance. The care plan reviewed on 10/30/2025 identified the resident as at risk for elopement and included a goal that the resident would not successfully elope and would have whereabouts monitored, with interventions for a wander guard to the left ankle, shift-by-shift monitoring for elopement risk, and monitoring for tailgating when visitors were on the unit. The care plan did not reflect the resident's actual elopements, did not include resident-specific interventions based on identified triggers, enhanced monitoring for behaviors, redirectional activities, wander risk assessments, or increased supervision such as 1:1 rounding supervision as ordered. Staff later stated that safety measures were put into place after the resident returned from the specialty hospital, including admission to the secured nursing unit, a wander guard bracelet, and 1:1 non-clinical observation.
Failure to Revise Care Plan for High Wander Risk
Penalty
Summary
The facility failed to revise the care plan to address the needs of Resident #5, who was identified as a high wander risk. Record review showed the resident had a Wander Risk Score of 13, with scores above 11 indicating high risk, based on an assessment dated [DATE]. The care plan, initiated on 4/3/25 and revised on 5/1/25, identified the resident as resistive to care and exhibiting wandering related to adjustment to the nursing home, but it was not revised to include interventions for the increased risk or the need for increased supervision despite the documented wandering behaviors and high-risk score. During interview, the DON and NHA confirmed that Resident #5 was not on the wander list and that the required quarterly assessment had not been completed since 6/27/25. The overdue wander risk assessment was later completed on 11/14/25 after surveyor identification, and the resident then had a Wander Risk Score of 17.
Unlocked Medication Cart Observed Unattended
Penalty
Summary
The facility failed to ensure safe storage of medications when, during the survey team's initial tour on 11/13/25, a medication cart on 1 of 10 nursing units was observed with the metal button protruding outward, indicating the cart was unlocked, and it was unattended in the resident hallway. Surveyors further observed that all drawers of the cart, which contained various medications, could be opened. Surveyors attempted to locate facility staff and then informed staff at the nurse's station, where RN #3 responded and confirmed responsibility for the medication cart. The concern was then shared with the DON, who acknowledged understanding, and later with the Administrator.
Incomplete Wandering Risk Assessments and Inaccurate Resident Risk Documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices related to residents’ wander risk status and required assessments for 2 of 16 residents reviewed for wandering/elopement. For one resident, the electronic record showed a high wander risk score of 13 from an assessment completed on 6/27/25, but the resident was not included on the facility’s wander list and no quarterly assessment was documented after that date. The resident’s care plan, documented on 4/3/25 and revised 5/1/25, noted wandering behaviors related to adjustment to the nursing home, but the incomplete and inaccurate documentation did not reflect the resident’s current risk status and need for monitoring. The DON and administrator acknowledged that the quarterly wander assessment had been missed and that the resident’s risk status was not reflected on the wander list. For another resident, the record contained a nursing progress note dated 1/23/25 stating the resident was busy seeking exit and wanted to go to floor 2 and go home, and the facility reported that the resident eloped on 3/6/25. However, the resident’s wandering risk assessments were incomplete and scored 0, including a readmission assessment, despite instructions that the assessment be completed on admission, readmission, with a change of condition, and annually. The facility policy also stated residents would be screened upon admission, whenever there is a change regarding wandering, and quarterly. The facility failed to complete an updated wandering risk assessment that recognized the resident’s exit-seeking behavior and failed to complete an accurate assessment that recognized the elopement event.
Failure to Timely Report Alleged Abuse and Injuries
Penalty
Summary
The facility failed to report alleged violations of abuse as required, affecting five residents. For Resident #11, the facility did not submit a final investigation or follow-up report to the Office of Healthcare Quality (OHCQ) after an initial report of a hip fracture was made. The Nursing Home Administrator (NHA) was unable to provide the final report and acknowledged the oversight. Similarly, for Resident #217, an allegation of abuse was documented in the resident's medical record, but no facility reported incidents (FRI) were found, and the NHA was unaware of the documented allegation. In another case, Resident #195 alleged abuse by a Geriatric Nursing Assistant (GNA), and the facility sent both the initial and final reports to OHCQ together, which was not in compliance with the required reporting timeline. For Resident #39, the facility reported a change in condition related to knee pain and swelling nine hours after the event, exceeding the two-hour reporting requirement. The Director of Nursing (DON) acknowledged the delay in reporting. Additionally, for Resident #147, a GNA reported multiple bruises, which should have been reported immediately to OHCQ. However, the facility's initial report was sent almost 16 hours later. The DON confirmed the delay in reporting. These incidents highlight the facility's failure to adhere to timely reporting requirements for suspected abuse, neglect, or injury of unknown origin, as mandated by regulations.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately document resident assessments on the Minimum Data Set (MDS) for four residents. For one resident, the MDS assessment inaccurately recorded the discharge date to the hospital, which was corrected after the surveyor's review. Another resident's MDS assessment inaccurately coded the presence of an indwelling catheter and urinary continence, as well as bowel continence, which was acknowledged by the Director of Clinical Reimbursement. Additionally, a resident's MDS assessment failed to note missing front teeth, despite the resident's statement and visible evidence of missing teeth. Another resident with bilateral contracted hands was observed without splints, and the MDS assessments inaccurately reflected the resident's upper extremity impairments. These inaccuracies were confirmed by the Clinical Director of Reimbursement during the surveyor's investigation.
Unauthorized Recording in Clinical Area
Penalty
Summary
The facility failed to protect residents' private space from unauthorized photographs and recordings, as evidenced by an incident involving Staff #19. On a specific date, Staff #19 recorded themselves in a common care area within Household 5 and posted the video on the social media platform TikTok. Although Staff #19 claimed that no residents were recorded, the act of recording in a clinical area was deemed inappropriate. The employee file review revealed that Staff #19 was terminated for Gross Misconduct due to this incident. Interviews with the Director of Nursing confirmed that Staff #19 had received education on resident rights and HIPAA during orientation. The incident was reported anonymously to the administration, and no specific resident was involved in the recording.
Failure to Protect Residents from Abuse and Aggression
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse, as evidenced by an incident involving a resident who was under 1:1 care due to confusion and high fall risk. A Registered Nurse reported hearing a 1:1 sitter shouting from the resident's room, where the resident was found in a precarious position. The facility's investigation revealed that a Certified Nursing Assistant (CNA) was accused of providing rough care, including hitting the resident with a flashlight and yelling. A witness corroborated the rough handling but not the flashlight incident, describing the CNA's actions as grabbing the resident and slamming them into a wheelchair, causing distress to the resident and fear in a roommate who witnessed the event. Another incident involved a resident with severe cognitive impairment who was pushed by another resident, resulting in a fall. The aggressor admitted to pushing a linen cart that knocked the resident to the floor, motivated by frustration over wandering residents entering their room. The facility's investigation noted that the aggressive resident had a history of behavioral issues, including threats to harm others, and interventions were in place to manage these behaviors. However, the incident highlighted a failure to prevent the aggressive behavior and protect the vulnerable resident from harm.
Failure to Document Investigation of Resident Incident
Penalty
Summary
The facility failed to maintain pertinent documentation of a reported investigation for a facility-reported incident involving a resident. The incident involved a resident who was sent out for further evaluation due to fever, tachycardia, and hypotension. The facility identified an error where a nurse incorrectly entered medications from the discharge summary. The resident's hospital course included altered mental status and hypotension requiring pressor support, ongoing leukocytosis, and treatment with empiric meropenem for possible sepsis. The Director of Nursing was unable to provide hospital records, citing HIPAA concerns, although the surveyor was able to obtain these records directly from the hospital.
Inadequate Evaluation of Pain Medication Effectiveness
Penalty
Summary
The facility failed to adequately evaluate the effectiveness of pain medication for a resident, as evidenced by the review of records and staff interviews. A complaint was made regarding a resident who did not receive medications, including tramadol, as ordered. The resident had an order for tramadol, an opiate pain relief medication, to be administered as needed for moderate to severe pain. However, the administration notes revealed that the effectiveness of the medication was evaluated 7 hours and 30 minutes after one administration and approximately 12 hours after another, which is not in line with the standard practice of evaluating effectiveness between 1 to 2 hours after administration. During an interview, the Director of Nursing stated that the expectation was to reevaluate pain 30 minutes after administration, indicating a discrepancy between the facility's practice and the standard of care. This deficiency was evident for one resident out of fourteen reviewed for pain management.
Inappropriate Care by CNA Leads to Deficiency
Penalty
Summary
The facility failed to provide a resident with an employee who practiced the appropriate skill set according to their education, leading to a deficiency in care. Resident #201, who was readmitted to the facility due to multiple falls and was very confused at baseline with impaired gait and a high fall risk, was ordered to have a 1:1 sitter. However, the sitter, identified as CNA #32, allegedly provided rough care to Resident #201, as reported by the resident and witnessed by the roommate, Resident #46. The roommate described CNA #32 as grabbing Resident #201 by the wrists, ankles, and feet, and slamming the resident into a wheelchair. The Director of Nursing (DON) clarified that the role of a sitter is to monitor and communicate the needs of the resident with nursing staff and that direct hand contact is not allowed unless the sitter is a Certified Geriatric Nursing Assistant (GNA). CNA #32 acted outside of her scope of practice by having direct hand contact with Resident #201, which led to the termination of her employment. This incident highlights the facility's failure to ensure that staff members have the appropriate competencies to care for residents, particularly those with high fall risks and confusion.
Medication Errors on Admission Lead to Deficiency
Penalty
Summary
The facility failed to protect a resident from significant medication errors by inaccurately ordering medications upon admission. This deficiency was identified for a resident with a diagnosis of Heart Failure, Chronic Kidney Disease, and Peripheral Vascular Disease. Upon admission, the nurse incorrectly entered medications from the discharge summary into the resident's chart as active medications. The medications involved included Lasix (Furosemide), Quetiapine Fumarate, Metoprolol Tartrate, and Sacubitril-Valsartan. These medications were administered in dosages and frequencies that differed from those prescribed during the resident's hospital stay. The discrepancies in medication orders included differences in dosage, frequency, and type of medication release. For instance, Metoprolol Tartrate was given instead of Metoprolol Succinate, and Quetiapine Fumarate was scheduled daily rather than as needed. These errors were discovered after the resident was sent to the hospital for evaluation due to confusion, tachycardia, and hypotension. The hospital records indicated that the resident was admitted with a diagnosis of Sepsis due to a UTI, which was treated successfully, resolving the symptoms. The facility's medication reconciliation process, as explained by a staff member, involves reviewing the discharge summary and consulting with the provider, but this process failed in this instance.
Failure to Notify Resident Representatives of Care Plan Changes
Penalty
Summary
The facility failed to notify the Responsible Party (RP) of a change in the care plan for two residents, leading to a deficiency in resident rights. For Resident #51, the facility did not inform the RP, who was the resident's daughter, about a new skin tear documented on 8/20/24. Despite the Director of Nursing (DON) acknowledging that the RP should have been notified, there was no documentation to confirm that this notification occurred. Similarly, for Resident #40, the facility did not ensure the involvement of the resident's co-guardians in the care planning process. Although a care plan meeting was documented on 7/17/24, there was no evidence that the family was invited or attended. The DON confirmed the lack of documentation regarding the family's involvement in the care plan meeting held in July 2024, further highlighting the facility's failure to uphold the resident's rights.
Failure to Maintain and Offer Advance Directives
Penalty
Summary
The facility failed to maintain proper documentation of Advance Directives for two residents during an annual survey. For one resident, the Medical Orders for Life-Sustaining Treatment (MOLST) certification indicated that Advance Directives were selected, but no document was found in the medical record. The Director of Social Service stated that Advance Directives information was integrated into the facility's internal system and did not see the need to maintain separate records. However, the Director of Nursing acknowledged the deficiency and later provided a copy of the Advance Directives from the hospital's record. For another resident, the surveyor found that the resident was capable of making medical decisions but did not have Advance Directives on file. A psychosocial assessment noted the absence of Advance Directives, and a progress note indicated that the resident had requested information about Advance Directives to be sent to a family member. The Director of Social Service admitted that there was no specific area in the psychosocial assessment to indicate if the resident was offered the opportunity to create Advance Directives, leading to uncertainty about whether the resident was given this option.
Failure to Inform Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to inform the primary care physician of a resident's need to alter treatment, specifically regarding episodes of vomiting and bowel movement irregularities. The resident, who was admitted in early 2021 with a percutaneous endoscopic gastrostomy (PEG) tube for feeding, experienced multiple episodes of vomiting throughout October and early November 2024. Despite these occurrences, orders to hold or restart the tube feeding were only documented on two specific days. Additionally, the resident went several days without a documented bowel movement on two separate occasions, which was not communicated to the physician as per the facility's bowel management policy. The physician, upon a follow-up visit, noted the resident's chronic vomiting and the lack of bowel movements, which led to the prescription of a new bowel regimen. However, the physician was not informed of the full extent of the vomiting episodes or the frequency of tube feeding interruptions. This lack of communication and failure to adhere to the facility's policy on bowel management contributed to the deficiency identified by the surveyor.
Failure to Notify Ombudsman of Resident Transfers to Hospital
Penalty
Summary
The facility failed to provide timely notification to the Ombudsman regarding the transfer of residents to the hospital, as required by regulations. This deficiency was identified during a survey, which revealed that the facility did not notify the Ombudsman of Resident #191's transfer to the hospital on 7/20/2024. The Nursing Home Administrator (NHA) acknowledged that the notification was not done for this transfer because the resident was expected to return to the facility. Although the NHA provided documentation of an email sent to the Ombudsman on 8/5/2024, it did not include the transfer on 7/20/2024, only the transfer on 7/29/2024. Similarly, the facility failed to notify the Ombudsman of Resident #30's transfer to the hospital on 4/20/2024. During an interview, the Administrator admitted that the resident was not included in the report of discharges and transfers sent to the Ombudsman for April. Resident #30 had a history of UTIs and was hospitalized for sepsis from a UTI. The facility acknowledged the oversight and indicated that changes were made to ensure proper notification in the future.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a written notice of its bed hold policy to the resident's legal guardian upon the resident's transfer to an acute care facility. This deficiency was identified during a review of the medical records and interviews conducted by the surveyor. Specifically, the medical record review revealed that the resident was transferred to the hospital on two occasions, but there was no documentation indicating that the bed hold policy was communicated to the legal guardian. The Director of Nursing confirmed that the facility's process involved sending the bed hold policy in a packet to the hospital and mailing it to the responsible party or guardian, but acknowledged that there was no documentation to support that these actions were taken for the resident's transfers.
Failure to Include Residents in Care Plan Meetings
Penalty
Summary
The facility staff failed to ensure that residents were able to participate in their care plan meetings, as required. Specifically, Resident #147 was not invited to participate in their care plan meeting, despite being capable of making their needs known. The care plan meeting was conducted without the resident or their family, and decisions were made by the care team alone. This pattern of exclusion was noted in previous care plan meetings as well, where neither the resident nor their family were involved in the decision-making process. Staff #6 admitted to not discussing the care plan meeting with the resident, leaving it up to the family, which resulted in the resident being excluded from the process. Additionally, the facility failed to conduct a care plan meeting following Resident #51's quarterly Minimum Data Set (MDS) assessment. While a care plan meeting was held after the July MDS assessment, there was no documentation of a care plan meeting following the October assessment. The Director of Nursing acknowledged that a meeting should have been held and attempted to locate documentation, but none was provided by the time of the survey exit. This oversight indicates a failure to adhere to the required care planning process after each MDS assessment.
Failure to Provide Music Activities for Resident
Penalty
Summary
The facility failed to provide an activities program tailored to meet the interests and needs of a resident, as evidenced by the case of a resident who had a strong interest in music. Despite the resident's family bringing in a music player and requesting music therapy, the facility did not adequately incorporate music into the resident's care plan. The resident's care plan indicated a dependency on staff for emotional, intellectual, physical, and social needs, with music engagement listed as an intervention. However, the facility did not consistently offer music-related activities to the resident. Interviews and record reviews revealed that the resident's activity log showed infrequent music-related activities, with only a few documented instances over several months. The therapeutic recreational re-assessment initially did not include music listening as an activity, although it was later checked in a subsequent assessment. Despite the care plan's emphasis on music engagement, the resident was offered activities less than weekly, indicating a failure to meet the resident's documented needs and preferences.
Failure to Administer TED Hose as Ordered
Penalty
Summary
The facility failed to provide treatments according to a resident's plan of care, specifically for skin care. Resident #77 reported swelling in both lower legs and was recommended by a Nurse Practitioner to use Thrombo-Embolic Deterrent (TED) hose to prevent blood clots and swelling. An order was placed for TEDs to be applied during the day and removed at night. However, there was no documentation in the resident's medical record indicating that the TEDs were applied as ordered. The Nursing Home Administrator confirmed that the order for TEDs did not translate to the Treatment Administration Record (TAR), resulting in a lack of documentation that the treatment was provided. Observations revealed that the resident's feet were swollen, and the resident reported that the TEDs had not been worn for weeks.
Failure to Replace Missing Hearing Aids for Resident
Penalty
Summary
The facility failed to ensure that a resident in need of hearing aids received services to obtain replacements after misplacing them. The resident, who had a documented communication problem related to a hearing deficit in both ears, lost their hearing aids on October 29, 2023. Despite a care plan update on December 29, 2023, indicating that the resident's brother would order new hearing aids with insurance coverage, the resident remained without hearing aids for over three months. The Treatment Administration Order required staff to check and assist with the application of hearing aids every shift, but notes indicated that the hearing aids were missing 13 out of 62 times. The facility's social worker assistant documented a care plan meeting with the resident's brother on July 10, 2024, and a follow-up on October 9, 2024, to discuss the missing hearing aids. However, it was confirmed during an interview on November 12, 2024, that the resident's brother did not want to pay for replacements, and guest services needed to proceed with obtaining new hearing aids. This lack of resolution resulted in the resident being without necessary hearing aids for an extended period, impacting their ability to communicate effectively.
Failure to Provide Appropriate Splinting Care for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment to prevent further decreased range of motion for a resident. During an observation, splints intended for the resident were found off and placed in the corner of the room. The resident's family member was unclear about the usage of the splints, and the resident had contracted hands. A registered nurse was interviewed and stated that the resident was being trialed for splint tolerance by therapy before a hospital visit. However, the nurse was not aware of any splinting schedule for the resident, which is typically provided by therapy once the resident tolerates the splints for a certain duration. Further review of the resident's occupational therapy notes revealed that the resident had previously tolerated passive range of motion exercises and was able to wear a resting hand splint for a limited time on one hand. However, there was no current splinting schedule in place after the resident's return from the hospital. The rehab manager confirmed that the resident was not on the schedule for splinting needs assessment after returning from the hospital, although the resident would benefit from it. This lack of coordination and communication between therapy and nursing staff led to the deficiency in care.
Inadequate Supervision During ADL Care Leads to Resident Fall
Penalty
Summary
The facility failed to adequately supervise and assist a dependent resident during Activities of Daily Living (ADL) care, leading to an accident. On 10/22/24, a progress note by a Nurse Practitioner documented that a resident sustained a fall after attempting to transfer themselves to a bedside commode. The Geriatric Nursing Assistant (GNA) had assisted the resident to the edge of the bed and helped them stand up but left the room before the resident completed the transfer to the commode. The resident had a care plan initiated on 10/21/24, indicating a self-care deficit related to impaired mobility, with an intervention requiring assistance with toileting. The Director of Nursing confirmed that the GNA did not follow protocol, and the resident should not have been left alone.
Deficient Tube Feeding and G-tube Care
Penalty
Summary
The facility staff failed to adhere to appropriate tube feeding treatment and gastrostomy tube (G-tube) site care for a resident with a history of hemiplegia after a stroke, dysphagia, and dementia. Observations revealed that the resident's feeding pump was turned off, yet the feeding tubing remained connected to the G-tube without proper labeling or dating of the formula bottle. This was observed on multiple occasions, indicating a lack of compliance with the facility's tube feeding treatment policy. Additionally, the G-tube site dressing was not changed as per the physician's orders, which required it to be cleaned and dressed twice daily. The dressing was found to be dated with the previous day and showed signs of oozing drainage. The on-duty nurse failed to ensure the Nepro container was labeled, the feeding tubing was disconnected at the appropriate time, and the G-tube site dressing was changed as required. These deficiencies were communicated to the Nurse Manager and the Director of Nursing as concerns.
Failure to Conduct Bed Rail Assessment and Obtain Consent
Penalty
Summary
The facility failed to conduct a bed rail assessment and obtain informed consent prior to the use of bed rails for a resident. The resident, who had a medical history of hemiplegia affecting the left side and muscle weakness, was observed with all four bed rails raised while grabbing onto one of them. Despite the care plan indicating the need to discuss concerns regarding diagnoses or treatments with the resident or their family, there was no documentation of a bed rail evaluation or consent in the resident's medical record. During interviews, the Nursing Home Administrator (NHA) acknowledged the absence of a bed rail assessment and mentioned that the resident was in a specialty bed that required the bed rails to be up for proper functioning. The facility's clinical engineering, shared with a hospital on campus, was not involved in evaluating the risk of entrapment. The Corporate Director of Clinical Operations confirmed that their department only serviced the beds when malfunctioning and did not assess for entrapment risks. The Specialty Bed Instruction for Use manual emphasized the need for assessing entrapment risks and obtaining appropriate medical personnel's determination for siderail usage, which was not adhered to in this case.
Failure to Implement Pharmacist's Recommendation
Penalty
Summary
The provider failed to follow through with a pharmacist's recommendation after a medication regimen review for a resident. During a pharmacy medication review, the pharmacist recommended discontinuing Novolog and checking the resident's A1C levels. The provider agreed to this recommendation and signed the documentation. However, upon review, it was found that Novolog remained an active order, and there was no order for an A1C lab test. The Director of Nursing confirmed that the expectation is for providers to write orders at the time of signing the recommendation if they agree with it.
Discrepancies in Medical Records and Code Status Documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with acceptable professional standards and practices, as evidenced by discrepancies in the medical records of three residents. For one resident, there were two conflicting bed rotation orders in the medical record. The first order specified a 50% turn to the right and left for 5 minutes, while the second order specified a 40% turn with a 0.5-minute pause. Both orders were marked as completed, indicating a lack of clarity and potential confusion in care delivery. The Director of Nursing acknowledged the error, noting that the first order was a standard one, while the second was placed by the treatment team. Additionally, discrepancies were found in the code status documentation for two other residents. The paper charts indicated a 'No CPR' status, while the electronic records stated 'Full Code' with a reference to the MOLST form. Interviews with nursing staff revealed that the expectation was to use the most up-to-date MOLST in the paper chart to determine code status. However, the inconsistency between paper and electronic records was only corrected after surveyor intervention, highlighting a failure in maintaining accurate and consistent medical records.
Failure to Respect Resident's Right to Refuse Care
Penalty
Summary
The facility failed to honor and respect a resident's wishes regarding Activities of Daily Living (ADL) care, resulting in a deficiency related to resident rights. A resident, identified as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, communicated that a Geriatric Nursing Assistant (GNA) held them down and performed care against their expressed wishes. The resident was able to communicate their refusal through nodding, mouthing answers, and using electronic devices. Despite the resident's clear refusal, the GNA proceeded with the care, citing instructions from other staff members to check for incontinence even if the resident refused. The facility's investigation revealed that the GNA attempted to perform the care by pulling the covers from the foot of the bed and holding the resident's arm across them, despite the resident's resistance. The Director of Nursing (DON) confirmed the incident and acknowledged that the GNA should have respected the resident's right to refuse care. The GNA involved was subsequently suspended and placed on the facility's do-not-return list.
Resident Restrained by GNA Against Their Will
Penalty
Summary
The facility failed to protect a resident from being physically restrained by an employee, which was evident in the case of one resident reviewed for abuse. The incident involved a Geriatric Nursing Assistant (GNA) who restrained the resident during care. The resident, who was assessed as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, communicated that the GNA held them down and performed care that they had expressed was not wanted or needed. The resident confirmed the incident during an interview with the surveyor. The GNA involved in the incident stated that they were instructed by other staff to check the resident for incontinence even if the resident refused. Despite the resident's clear communication of refusal, the GNA proceeded to pull the covers from the foot of the bed and held the resident's arm across their body to perform the check. The Director of Nursing confirmed the GNA's actions and acknowledged that the resident should not have been restrained in this manner.
Failure to Implement Behavior Management Care Plan
Penalty
Summary
The facility failed to implement interventions in a care plan for a resident with behavior problems, which led to an incident involving physical aggression. On March 14, 2024, a resident pushed another resident, causing them to fall. The incident occurred because the resident felt their privacy was invaded by another resident wandering into their room. The resident had previously communicated to staff that they would harm wandering residents if they entered their room. Despite this, the care plan initiated on July 12, 2023, which identified the resident's triggers for aggression and outlined interventions such as removing other residents from their room and increasing supervision, was not effectively implemented, leading to the incident.
Failure to Provide Timely Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services according to the identified individual needs in the care plans of three residents. Resident #105, who had a care plan for altered thought processes and mood disturbances related to dementia and major depressive disorder, was observed exhibiting hallucinations and disruptive behavior. Despite documentation indicating that psychiatric services were closely monitoring the resident, there were significant gaps in psychiatric visits, with no documented services from January to October 2024. This lack of consistent psychiatric follow-up contributed to the deficiency in care. Resident #245 was observed to be restless and anxious, with behaviors such as pulling at medical equipment. Although a psychiatric consultation was ordered due to agitation, the consultation was delayed because the provider was not informed in a timely manner. Similarly, Resident #214, who exhibited behaviors requiring multiple antipsychotic medications, experienced a delay in receiving a psychiatric consultation. The need for the consult was identified on May 17, 2024, but the order was not placed until nine days later. These delays in providing necessary psychiatric services highlight the facility's failure to meet the behavioral health needs of its residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blue Point Healthcare Center | 0.2 mi | ★★★★★ | 27 | 0 |
| Northwest Healthcare Center | 0.8 mi | ★★★★★ | 16 | 0 |
| Roland Park Rehabilitation And Healthcare Center | 1.4 mi | ★★★★★ | 9 | 1 |
| Autumn Lake Healthcare At Arlington West | 1.5 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Alice Manor | 1.6 mi | ★★★★★ | 1 | 0 |
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