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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during a recertification survey from 1/22/25 to 1/30/25, the facility did not ensure a person centered comprehensive care plan was developed and/or implemented for 1 of 1 resident (#78) reviewed for Hospice Care. Specifically, there was no documented evidence that a care plan was developed when Residents #78 was put on hospice care on 1/15/ 25. The findings include: Resident #78 was admitted to the facility with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (resident assessment) dated 11/20/24 documented the resident's cognition was severely impaired. The 1/14/25 Health Status Note documented hospice came today to do a consult. As per the nurse practitioner the resident will start on hospice tomorrow 1/15/ 25. There was no documented evidence that a care plan was developed when Residents #78 was put on hospice care on 1/15/ 25. The 1/16/25 Social Service Note documented the social worker was informed hospice accepted the resident onto hospice care effective 1/15/ 25. Team informed. During observation on 1/22/25 at 12:21 PM the hospice aide was trying to feed Resident # 78. During an interview on 1/29/25 at 11:57 AM, Registered Nurse Supervisor #3 stated they did not initiate the hospice care plan and it was their responsibility to develop the care plans. Registered Nurse Supervisor #3 stated they did not develop the care plan because they had time off from the facility and had just returned to work 2 days prior. 10NYCRR 415. 11(c)(1) | Plan of Correction: ApprovedMarch 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: At(NAME)Neuman all residents on hospice care a Terminally Ill care plan is generated,and in the care plan it is indicated resident is on hospice care. Care plan states resident was on hospice dated 01/15/25 with listed interventions for terminally ill care. Registered nurses will be in-serviced to update care plan to reflect services provided to residents on hospice care. In-service on care planning will also be provided to all clinical staff and continue on annual basis to ensure compliance. This training will be extended to all clinical new hires including contract staff. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). All residents admitted to the hospice program have the potential to be affected by this deficient practice. The Director of Social Work will generate a list of all residents on the hospice program and this list will be to update the care plans of the residents on the hospice program. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. Policy of Comprehensive Care Plans was reviewed and was found to be in compliance. An audit tool will be utilized to validate compliance with hospice care planning. The IDT team was educated on the need to develop a comprehensive care plan and implement for all residents on Hospice. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) Director of Nursing or Designee will conduct audits 1 X week for one month and 1 X month X three Months. Data collected from the audit process will be reported to the QAPI committee monthly for three months for action appropriate. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted from 1/22/2025 to 1/30/2025, the facility did not ensure residents who required [MEDICAL TREATMENT] (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) received services consistent with professional standards of practice for 1 of 1 resident (Resident #163) reviewed for [MEDICAL TREATMENT]. Specifically, there was no documented evidence of consistent assessment and oversight before, during and after [MEDICAL TREATMENT] treatment for [REDACTED]. Findings include: Policy and Procedure Titled [MEDICAL TREATMENT] dated (MONTH) 2011 and last reviewed 10/29/2024 documented resident's receiving [MEDICAL TREATMENT] treatments will be monitored. If resident had an arteriovenous fistula check for the presence of thrill and bruit daily. The nurse's responsibility to document in the progress notes residents condition including vital sign, post [MEDICAL TREATMENT], weight and presence of arteriovenous fistula's thrill and bruit upon return from [MEDICAL TREATMENT]. Resident #163 had [DIAGNOSES REDACTED]. The Care Plan titled [MEDICAL TREATMENT] dated 4/25/23 documented appointment time 10:30 AM Tuesday, Thursday, Saturday. The Annual Minimum Data Set (an assessment tool) dated 12/6/2024 documented the Resident #163 had severely impaired cognition and received [MEDICAL TREATMENT] while a resident. The current Physician order [REDACTED]. The (MONTH) 2025 Medication Administration Record [REDACTED] 25. The [MEDICAL TREATMENT] Communication Book had inconsistent documentation and did not contain pre and post [MEDICAL TREATMENT] notes from the [MEDICAL TREATMENT] center. The 12/22/24-1/25/25 Progress Notes documented on 12/23/24 returned from [MEDICAL TREATMENT] at 1702 stable with positive bruit/thrill at the arteriovenous fistula, 12/30/24 resident out to [MEDICAL TREATMENT], 1/4/25 resident out to [MEDICAL TREATMENT] returned to unit at 4:30 PM stable, 1/11/25 resident alert and responsive came back from [MEDICAL TREATMENT] in stable condition. 1/25/25 resident out to [MEDICAL TREATMENT] at 10:30 am in stable condition, vital signs stable, will return in PM. 1/25/25 resident was in the hospital because the shunt was clogged. There was no documented evidence of pre and post [MEDICAL TREATMENT] notes in the progress notes on 1/2/25, 1/7/25, 1/9/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25 and 1/23/ 25. During interview on 1/23/25 at 10:19 AM Registered Nurse Unit Manager # 7 stated the resident went to [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday and brought the communication book in the backpack on the back of the Wheelchair. Registered Nurse Unit Manager #7 stated the book had inconsistent documentation, and did not contain pre and post [MEDICAL TREATMENT] documentation. During interview on 1/24/26 at 10:07 AM and 1014 AM Assistant Director of Nursing #1 stated they reviewed the [MEDICAL TREATMENT] book and noted documentation was inconsistent, and [MEDICAL TREATMENT] staff were not writing in the book. Assistant Director of Nursing #1 stated they thought nurses were writing pre and post [MEDICAL TREATMENT] progress notes. They stated they were not aware staff at the [MEDICAL TREATMENT] center should have written in the communication book. Assistant Director of Nursing #1 stated they spoke with [MEDICAL TREATMENT] center staff, and were told the center had their own progress notes and did not send those notes to the facility unless requested. During interview on 1/27/25 at 11:02 AM the [MEDICAL TREATMENT] center Registered Nurse Manager stated they had poor communication with the facility and calls to the facility often went unanswered. They stated at times documents including labs and recommendations were sent to the facility but staff at the [MEDICAL TREATMENT] center did not write in the communication book. During interview on 1/27/25 at 11:45 AM the Director of Nursing stated the use of the communication book stopped during Covid-19 and they were not aware the book was still not being used. They stated they expect facility staff would be checking the resident pre and post [MEDICAL TREATMENT] and writing a progress note. They stated they would expect staff to check the communication book when the resident returned from [MEDICAL TREATMENT] and reach out to the [MEDICAL TREATMENT] center if nothing had been written in the communication book. 10NYCRR 415. 12(k) | Plan of Correction: ApprovedMarch 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. What corrective action will be accomplished for the resident affected by the deficient practice? The was no harm to the resident affected by the deficient practice. The [MEDICAL TREATMENT] communicated with facility via email or telephone when there are changes. The [MEDICAL TREATMENT] center was contacted and has agreed to update resident's notebook pre and post [MEDICAL TREATMENT] to keep facility update with resident care while at [MEDICAL TREATMENT]. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice? A facility wide audit will be conducted to identify whether there any other residents receiving [MEDICAL TREATMENT]. There are no other residents currently receiving [MEDICAL TREATMENT]. All newly admitted [MEDICAL TREATMENT] residents will receive a care plan for [MEDICAL TREATMENT] to ensure consistent monitoring. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. To prevent the deficient practice all nursing staff will receive training and education on the [MEDICAL TREATMENT] policy to ensure that the appropriate assessment and oversight occurs pre-and post [MEDICAL TREATMENT]. This education will include review and update of the resident care plan,required documentation from the community [MEDICAL TREATMENT] center pre and post [MEDICAL TREATMENT] and required documentation by nursing staff for residents on [MEDICAL TREATMENT] including assessment of the arteriovenous fistula.This training will be completed by the Nurse Educator and/or designee. Review and update all [MEDICAL TREATMENT] care plan quarterly and as needed based on changes. Review residents on [MEDICAL TREATMENT] documentation three times weekly on [MEDICAL TREATMENT] days and provide real time remediation as needed. Identify a designated liaison nurse to the oversee [MEDICAL TREATMENT] communication and documentation compliance. Nursing supervisor/Nurse Manager and or designee will review resident communication book three times weekly to ensure pre and post [MEDICAL TREATMENT] documentation is completed 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur ? Director or Nursing and/or designee will conduct weekly audits of [MEDICAL TREATMENT] communication and documentation for one month. Results of audits will be reported to the QAPI Committee monthly by the Director of Nursing/Designees for 3 months to the QAPI committee for action as appropriate. |
Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the Recertification Survey from 1/22/25 to 1/30/25, the facility did not ensure Minimum Data Set Assessments were submitted within 14 days after the facility completed the resident's assessment for 2 of 2 residents reviewed for Minimum Data Set (Resident #129, Resident #225). The findings are: The facility's policy and procedure titled Resident Assessment Instrument/Minimum (MDS) data set [DATE] and revised on 10/1/24 documented ensure that the Resident Assessment Instrument is used as the basis for a uniform system of resident assessment and care planning by the Interdisciplinary Team. Review of the submissions revealed: - Resident #129's Quarterly Minimum Data Set 3. 0, with an assessment reference date of 11/15/24 and completion date of 11/20/24, was submitted on 1/24/ 25. - Resident #225's Quarterly Minimum Data Set 3. 0, with an assessment reference date of 11/18/24 and completion date of 11/27/24, was submitted on 1/24/ 25. During interview on 1/24/25 at 11:05 AM the Minimum Data Set Coordinator stated after reviewing the Minimum Data Set schedule they noted 2 assessments were not transmitted although completed. Someone changed the status in the medical record to do not transmit to Centers for Medicare Services. They stated they did not know why that happened. During interview on 1/25/25 at 10:55 AM, the Director of Nursing stated they were unaware of the delay in submitting the assessments. The Director of Nursing stated the Minimum Data Set Coordinator was responsible for submitting the assessments. 10 NYCRR 415. 11 | Plan of Correction: ApprovedMarch 10, 2025 The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: The two residents who are affected with the deficient practice are scheduled for a new MDS schedule. Resident #129 next MDS schedule 2/14/25, and resident #225 2/17/ 25. The status of submission will be monitored with the use of the Monthly MDS schedule, starting with their new schedule. There was no negative outcome from the late submission. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). All residents have the potential to be affected by this deficient practice. An audit was complete to review all MDs complete over the last 90 days and found that all were submitted timely. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. To ensure full compliance with the MDS schedules an audit tool/checklist will be utilized to monitor full compliance to the timely CMS submission. ?ôFacilities are required to electronically transmit MDS data to the CMS system for each resident in the facility.?Ø . An audit tool was developed to ensure all submission are submitted timely. A monthly MDS schedule that is derived from the PCC scheduler that the facility has been using was modified to include three columns: ?ôPREVIOUS MDS/ARD/TRANSISSION STATUS?Ø, ?ôEXPORT READY?Ø and ?ôACCEPTED?Ø. The MDS schedule of the next month is completed in the middle of the current month and modified ad lib. The RAUM Manager and/or checks her own assigned unit every week to ensure that MDSs are completed, locked with ?ôEXPORT READY?Ø status and checks the said column in the MDS schedule. The Director of the Clinical Compliance and/or designee will transmit the ?ôEXPORT READY?Ø status MDSs to CMS. Upon completion of the transmission process in PCC, the RAUM Manager and/or designee checks the ?ôACCEPTED?Ø column. A meeting with RAUM Managers and in-service regarding the transmission process. and this audit will be done on bi-weekly x two month, then bi-weekly x one month and then monthly thereafter. This process will be monitored by the Director of MDS and/or designee. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur The MDS Schedule, the MDS report in PCC and the IQIES report on MDS 3. 0 Missing assessments will be utilized to complete the audit tool. Audit will be done by Director of MDS or Designee bi-weekly x 1 month, then monthly for 3 months. Results of the Audits will be submitted to the Administrator and results of the audits will be reported to the QAPI meeting monthly for 3 months for action as appropriate. |
Scope: Pattern
Severity: Actual harm has occurred
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during the recertification and abbreviated surveys (NY 448, NY 98, NY 310, NY 372) from 1/22/2025-1/29/2025, the facility failed to ensure that four (4) of six (6) residents' (Resident, #534 #70, #207, #65) environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically: 1. Resident #534 was not supervised to prevent a fall from a wheelchair, which resulted in three (3) fractured ribs and a fractured scapula (shoulder blade); 2. Resident #70 required a mechanical lift and two-person physical assist for transfers. Certified Nurse Aide #24 used a sit to stand assistance device and one person for the transfer, resulting in a painful bruise on the left side of the forehead; 3. Resident #207 required a two-person assist for bathing, toileting, and transfers as documented in their plan of care however the assigned aide provided a one-person assist for bathing and the resident was later found with a bruise on their forehead. 4. Resident #65 required a mechanical lift and two-person physical assist for transfer. The resident was transferred with only one (1) assistant and had to be lowered to the floor. This resulted in actual harm that was not Immediate Jeopardy to Residents #534, #70, and #207 when Resident #534 sustained fractured ribs and a fractured scapula, and Residents #70 and #207 both sustained painful bruising. Findings include: The policy and procedure titled Resident Incident/Accident Reporting and Investigation Process revised 8/31/2022, documented the facility is to effectively investigate potential and actual injuries to resident to maximize resident care and minimize adverse resident outcomes. The licensed nurse notifies the nursing supervisor on duty of the accident/incident. 1. Resident #534 had [DIAGNOSES REDACTED]. The admission Minimum Data Set (an assessment tool) dated 3/20/2024, documented the resident was cognitively intact, required tray set up for eating, moderate assistance for toileting and Activities of Daily Living. The resident used a wheelchair, did not have wandering behaviors, and had a history of [REDACTED]. The Fall Risk tool dated 3/10/2024, documented the resident was at risk for falls. The Comprehensive Care Plan dated 3/16/2024, documented the resident needs a safe environment with even floors free from spills and or clutter, needs to be evaluated for and provided adaptive equipment (low bed and wheelchair), review information on past falls, attempt to determine cause of falls, and out of bed in common area while awake and restless. A psychiatry note dated 4/9/2024 documented Resident #534 had a history of [REDACTED]. The resident was minimally verbal, and their short-term memory, fund of knowledge, insight and judgment were limited. During a review of the Accident and Incident Reports and nurses' notes, the resident experienced seven (7) falls between 4/5/2024 and 5/25/2024 and four (4) of these falls resulted in injury. On 5/24/2024 Resident #534 sustained fractured ribs at levels #4, 5 and 6 and a fractured inner scapula following a fall. The Accident/Incident Report dated 4/5/2024, documented a witnessed fall where the resident was observed in their wheelchair in the dining room, and while changing position, slipped off the wheelchair onto the floor. The resident reported they were tired and wanted to go back to bed. The Accident/Incident Report dated 4/21/2024, documented Resident #534 was found kneeling in front of the wheelchair in their room. The resident stated they were trying to go to the bathroom and wanted to go back to bed. There were no injuries. Fall care plan updates included anticipate and meet the resident's needs, remind resident to use call bell to get help. The Accident/Incident report dated 4/23/2024 documented Resident #534 was observed on the floor in their room lying on their right side with the wheelchair tilted onto the right side. The resident was alert, awake, and moving all extremities. There was an abrasion noted to their right elbow. The Accident/Incident Report dated 4/27/2024, documented Resident #534 was observed lying on the floor in the dining room with their head on the baseboard and wheelchair turned over on the side and situated under them. A hematoma (clotted blood from a broken blood vessel) was noted in the occipital (back of head) area. A cool compress was applied, and neuro checks were started. The resident denied pain. A new Fall Care Plan intervention included for no apparent injury, determine and address causative factors of the fall, monitor, document, and report for 72 hours signs and symptoms of pain, bruising, change in mental status, new onset of confusion, sleepiness, inability to maintain posture and agitation. Purposeful rounding was also added. The facility had no documentation that defines Purposeful rounding. The Accident/Incident Report dated 4/28/2024, documented Resident #534 was found in the hallway with a small laceration (cut) to their left eyebrow. The Accident/Incident Report dated 5/7/2024, documented Resident #534 was found on the floor by the door to their room. The resident had a swollen raised area on the top, left side of their head which was bleeding. The resident to be placed by nurses' station for safety monitoring. The care plan updated 5/8/2024, documented the resident's room was changed so they would be closer to the nurse's station for observation. The Accident/Incident Report dated 5/25/2024, documented at 6:00 AM Licensed Practical Nurse #40 was informed by Certified Nurse Aide #41 of a bruise on the resident's back which was painful to the touch and was discovered while turning the resident on their side. There was no documented evidence of a recent fall. The Nursing Supervisor, Physician, and family were notified, and the resident was transferred to the hospital. During the facility investigation, it was determined there was an unwitnessed fall on 5/24/2024 while the resident was left unattended in the Southwest dining room. It was determined Certified Nurse Aide #43 and Food Service Worker #42 picked up Resident #534 from the floor without a Registered Nurse assessment. Licensed Practical Nurse #44 was aware the resident fell but did not notify the Nursing Supervisor, physician, or family about the fall. Resident #534 was returned to their room until a large bruise was identified during morning rounds on 5/25/2024 by Certified Nurse Aide #41, who in turn notified the nurse. On 5/28/2024, Food Service Worker #42 documented in their statement that on 5/24/2024 after 6:00 PM, they were coming from the bathroom and saw the resident on the floor in the Southwest dining room area and called out for someone to come and help. Certified Nurse Aide #43 asked Food Service Worker #42 to help them get Resident #534 off the floor and into the chair. Certified Nurse Aide #43 then wheeled the resident out of the dining room. During an interview with Food Service Worker #42 on 1/27/2025 at 10:15 AM, they stated they came out from the bathroom and saw resident #534 on floor, laying on their side and the wheelchair was on its side next to the resident. Certified Nurse Aide #43 came to the dining room and asked them (Food Service Worker #42) if they would help them get the resident into the wheelchair. Food Service Worker #42 stated they grabbed the resident by their pants and their arm and got the resident into the chair. They stated there was no other staff present in the dining room at that time. During an interview on 1/27/2025 at 11:08 AM, Certified Nurse Aide #43 stated they were on the facility computer and was told by Licensed Practical Nurse #44 that Resident #534 was on the floor and to go and get them off the floor. They further stated they were only doing what they were told. They stated they went to the dining room and picked up the resident with Licensed Pr | Plan of Correction: ApprovedFebruary 28, 2025 Directed Plan of Correction 1 .What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Nursing staff identified as responsible for the deficient practice were suspended and reeducated on the appropriate procedures or terminated by the Director of Nursing including: The CNA who did not utilize the correct mechanical lift in transferring the resident. was suspended and counselled on the facility policy regarding following the residents plan of care. On (MONTH) 7, 2024. The CNA who provided care alone when the resident required two persons due to behavioral issues was suspended and counselled on the facility policy regarding following the residents plan of care on (MONTH) 13,2024 The Agency LPN and CNA involved with moving the resident after a fall in the dining room before a nurse assessment was completed were terminated on (MONTH) 27, 2024. The Agency CNA who used the Hoyer lift without a second CNA in attendance was terminated on (MONTH) 4, 2024 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the deficient practice. The Director of Nursing and the Nursing Management team have reviewed all incidents over the last 90 days and have not identified any other Residents who were affected by the same deficient practice. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? Based upon the root cause analysis conducted by the QAPI committee the following corrective actions will be put into place: The policy/procedure for Fall Prevention and Management will be revised to address the areas identified during the QAPI meeting including timely notification of the RN prior to moving the resident and the purpose/function of purposeful rounding including the monitoring for pain and the new rounding schedule for all residents after a fall. The policy/procedure on Mechanical lifts will be updated to address the use of a Sit to stand lift and the requirements to verify the appropriate lift to be used as indicated in the residents task list in the Electronic Medical Record (EMR). New/revised policies and procedures will be developed to address all of the areas identified by the QAPI Committee including the start/end of shift huddle, safety committee guidelines, and supervision in the dining room. In-service training will be provided for all nursing staff on the new/revised policies and procedures regarding falls management including reporting of incidents, the timely notification of the RN at the time of the incident, supervision of residents in the dining room, use of mechanical devices, purposeful rounding and rounding schedules, and shift huddles and notification of the Nursing Supervisor when a licensed nurse does not respond to the incident. In-service will include a pre and posttest to measure staffs understanding and competency related to all of the new/revised policies and procedures. In-service will be provided to the Dietary staff who work in the Dining rooms on the protocol when there is a resident incident in the dining room and how to notify the Nursing Supervisor when a nurse does not respond to an incident. In-service will be provided to all ancillary staff (Housekeeping/Maintenance/ Social Service/ Recreation/ Rehab Therapy) on their role in responding to an incident and the procedure for notification of the RN when a resident falls. A handout will be provided which details the process for managing the incident and notifying the RN Supervisor. 4. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits tools will be developed based on the new/revised policies including Dining room Supervision, use of mechanical devices, observation of staff for residents requiring two CNAs during care delivery, documentation of RN Assessment at the time of the fall and the Frequent Falls Committee process. Audits will be conducted on each of the nursing units on two separate days on different shifts and different observation of different staff on the nursing unit. Audits will be conducted by the Nursing Management team, and the Managers/Supervisors in the individual departments as appropriate. Audits will be completed weekly for 4 weeks, then monthly for 3 months and results will be collated and presented to QAPI Committee at its monthly meeting. The QAPI Committee will determine a plan for additional ongoing monitoring based upon the results of the audits. A QAPI Meeting will be held prior to the Completion date to ensure that compliance is being achieved and that no additional training is required. The Director of Nursing and the RN Consultant will be responsible and will oversee the completion of this Directed Plan of Correction. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a recertification survey from 1/22/25-1/30/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection and did not ensure there was a system for preventing, identifying, reporting, investigating, and controlling infection and communicable disease for all residents. Specifically, 1) there was no evidence that a facility risk assessment was completed or that a water management plan was in place to prevent and control legionella and 2) an observation was made of Environmental Staff# 28 entering a contact isolation room to empty garbage bags without donning a gown or washing hands with soap and water before and after contact with the resident environment. The findings are: The policy titled Legionnaires' Disease: Prevention and Control revised (MONTH) 2, 2024, documented the director of plant operations reviews and updates, annually, environmental assessment of the water systems, this involves reviewing facility characteristics, hot and cold-water supplies, cooling and air handling systems and any chemical treatment systems (use form environmental assessment of water systems in healthcare settings). 1) There was no documented evidence that an environmental risk assessment and water management plan to identify Legionella and other opportunistic waterborne pathogens was updated and/or completed from (MONTH) 2023- January 2025. During an interview on 01/29/25 at 12:04 PM Director of Facilities and Lead Engineer stated the water management plan for Legionella was done by an outside agency. They also stated that they were not sure who was responsible for completing the risk assessment. The Director of Facilities was asked why neither had been updated yearly and they stated they were unsure and would try to retrieve any updated information. They also stated they became employed with the agency 4 months ago and were not aware of who was supposed to complete the water management plan and risk assessment. 2) Resident #588 was admitted with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (a resident assessment tool) dated 1/23/25 documented Resident #588 had moderate cognitive decline and was frequently incontinent of bowel. The Physician order [REDACTED]. The Care Plan dated 1/20/25 and revised 1/27/25 documented contact isolation, wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag, linens and close bag tightly before taking to laundry.Place in private room with contact isolation precautions. During an observation and interview on 01/22/25 at 11:02 AM, Environmental Service Worker #28 was observed entering Resident #588's room to change the non-surgical gowns only bin.They did not don/doff personal protective equipment or perform hand hygiene before or after entering the resident room. Environmental Services Worker #28 stated they did not pay attention to the sign on the door and thought the resident was on enhanced precautions only.They stated they were aware they should have reviewed signage, donned and doffed personal protective equipment and completed hand hygiene before and after contact with the resident environment. During an interview on 01/29/25 at 10:01 AM the Director of Nursing stated all staff, whether providing cares or not, were required to perform hand hygiene before and after entering resident rooms, and were required to don/doff personal protective equipment for residents on contact precautions, especially for residents with a [DIAGNOSES REDACTED]. During an interview on 01/29/25 at 10:27 AM the Infection Preventionist stated all staff entering resident rooms should check the door for precaution information and have a discussion with the unit nurse for precaution information. Personal protective equipment should be doffed inside resident rooms and hand hygiene should be performed before and after entering rooms.They stated that on 1/22/25, Resident #588 was on contract precautions for [MEDICAL CONDITION].They stated nursing staff and the director of environmental services provided supervision for environmental services staff on all units to ensure that infection control guidelines were being followed. 10 NYCRR 415. 19 | Plan of Correction: ApprovedMarch 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: Immediate training was provided to all Environmental staff worker on1/30/ 25. Immediate education was given to New Director of Plant Operations on The New Jewish Home Water Management Plan and Environmental Risk assessment and where all documents of such are kept. Administrator will meet monthly with New Director to review and ensure that necessary documentation is in place and new director is properly educated on all testing that is mandated for The New Jewish Home(NAME)Neuman. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). All residents have the risk to be potentially affected by this deficient practice. The New Jewish Home will continue to properly follow the Water management plan that was in place at time of Survey, but new Director failed to produce the information at the time he was asked. Water Management plan and records of legionella testing between dates of 11/23 and 1/25 were available in the facility at time of survey. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. Training will be provided on date of hire and bi-annually for all environmental service workers in regards to the Infection Control Policy. Training will ADON Infection Control and/or designee. The Director of Environmental Services and/or designee is responsible for scheduling the training sessions. The New Jewish Home will continue to comply with Water Management plan and Evaluation for Legionella, following regular testing and evaluation as plan states. The Administrator will educate Plant Operation leadership and Nursing Infection Control Manager to have a full understanding of the legionella policy, water management plan and ongoing testing. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Environmental Services and/or designee will be provided with a tool for rounding to ensure compliance with the Infection Control Policy. the completed audit tool will be submitted to the Infection Control Preventionist after the rounding. A verbal report of those employees requiring remediation will be communicated at the time the audit is submitted. The Director of Environmental Services and/or designee will conduct weekly audits for one month. Results of audits will be submitted to the Infection Preventionist and results of the audit will be reported to the QAPI committee monthly by the Infection Preventionist for 3 months to the QAPI committee for action as appropriate. Water Management plan review and reporting will be added to the facility QAPI meeting agenda quarterly. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the Recertification and Abbreviated Surveys (NY 430) from 1/22/25 to 1/30/25, the facility did not ensure residents or resident representatives were notified in writing of the facility bed hold policy for 1 of 3 residents (Resident #127) reviewed for hospitalization . Specifically, Resident #127 was transferred to the hospital and the facility was unable to provide evidence that written notice of facility bed hold policy was given to the resident or their representatives. The findings are: The facility policy and procedure, bed hold retention dated 11/9/2023 documented nursing will include a copy of the bed hold retention policy with the resident as part of the hospitalization documents. No policy was provided to document that the facility will notify residents or their representatives in writing of the facility bed hold policy. Resident #127 was admitted with [DIAGNOSES REDACTED]. The 12/25/24 Minimum Data Set Discharge Return / Anticipated Assessment documented the resident was discharged . The 12/25/24 Nursing Note documented the resident had several episodes of vomiting and diarrhea, vital signs 136/95, heart rate 94, Resp rate 19 temp 97. 5 O2 Sat 97% room air, complained of chills. The physician was notified and a telephone order for hospital transfer was given. At 5:15 AM, the resident was transferred to the hospital and the family was notified. There was no documented evidence a written notice of the facility Bed Hold Policy was given to the resident or their representative. On 01/27/25 at 12:15 PM the surveyor requested a copy of the notice of facility bed hold policy given to the resident or their representative, and notification that was sent to the Ombudsman. The Director of Social Work stated that no such documentation was available for review. The Director of Social Work stated they were responsible for sending the facility bed hold policy to the resident/representative. They stated they only sent the documents if a resident was admitted to the hospital, but if the resident was sent to the emergency room and returned without being admitted to the hospital, they did not send the notification of facility bed hold policy. 10NYCRR 415. 3 (i)(3)(i)(a) | Plan of Correction: ApprovedMarch 18, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: Resident was not admitted and returned to(NAME)Neuman within twenty-four hours. Social worker met with resident and family to discuss facility Behold policy. A copy of the Facility Notice of Behold Policy was also provide to the resident and next of kin. To correct the deficient practice, facility will identify all residents who are being transferred to the hospital as those in need to receive the Facility Notice of Behold Policy. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The Director of Social Work will review the transfer log in PCC to identify whether other residents were potentially affected by the same deficient practice. To correct the deficient practice, facility will identify all residents who are being transferred to the hospital as those in need of receiving the Facility Notice of Bedhold/discharge transfer notification policy. The Revised Bedhold/discharge transfer notification policy was reviewed at Resident Council and Family Council. 3.(NAME)Neuman reviewed and revised the Bed Hold Discharge Transfer Retention Notice Policy. The Bedhold Retention notification and the Hospital Transfer notice have been combined into one notification document. The Director of Social Work provided training and education on the updated policy to Nurse Managers, Unit Clerks and Social Workers. Nursing Supervisors are responsible for ensuring bed hold/discharge transfer notification letter are provided at the time of transfer. Social services is responsible for issuing bed hold letter for emergent transfers. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change.) To ensure the practice will not re-occur the Director and/or designee will conduct weekly audit of the transfer log x 1 month , then monthly x three months. If during the audit it is discovered that resident did not receive the notice this will remediate emailing to family or next of kin. The Director of Social Work or designee will submit results of the audits to the Administrator and results of the audits will be reported to the QAPI committee monthly for 3 months for action as appropriate. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during Recertification and Abbreviated Surveys (NY 430) from 1/22/25 to 1/30/25, the facility did not ensure residents and/or representatives were provided written notification in a manner they understood and that a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 residents (Resident #127) who was transferred/discharged to the hospital. The findings are: There was no documented evidence of a facility policy to address notification of residents or their representatives and the Ombudsman in writing of the reason for the resident's transfer to the hospital. Resident #127 was admitted with [DIAGNOSES REDACTED]. The 12/25/24 Minimum Data Set Discharge Return/Anticipated assessment documented Resident #127 was discharged . The 12/25/24 Nursing Note documented the resident had several episodes of vomiting and diarrhea, vital signs 136/95, heart rate 94, Resp rate 19 temp 97. 5 O2 Sat 97% room air, complained of chills. The physician was notified and a telephone order for hospital transfer was given. At 5:15 AM, the resident was transferred to the hospital and the family was notified. There was no documented evidence that the Ombudsman was notified of Resident #127's transfer to the hospital. On 01/27/25 at 12:15 PM the Director of Social Work stated they were responsible to send written notices of the reason for transfer and to send copies to the Ombudsman.The Director of Social Work stated that no such documentation was available for review. They stated they only sent the documents if a resident was admitted to the hospital, but if resident was sent to the emergency room and returned without being admitted to the hospital, they did not send notice of reason for transfer to the resident/representative or to the Ombudsman. The Director of Social Work stated they were not aware to send the notices unless a resident was admitted to the hospital 10NYCRR 415. 3 (i)(1)(ii)(a)(b) | Plan of Correction: ApprovedMarch 18, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: In the facility policy it states inform the family/representative and Ombudsman regarding facility's bedhold with 72 hours however resident #127 was not admitted and return to the facility within twenty- four hours. The resident was not negatively impacted by this deficient practice. 2. How will The New Jewish Home Sarah Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). A monthly transfer and discharge binder was developed by the Social Worker to cross-reference and ensure all notifications were included in a report at least monthly to the Office of State LTC Ombudsman. Copies of sent emails will be stored in this binder as evidence of compliance. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. Sarah Neuman reviewed and revised the Bed Hold Discharge Transfer Retention Notice Policy to ensure notices before transfer are issued and that the Office of State LTC ombudsman is notified in a timely manner. The Bedhold retention notification and the Hospital transfer notice have been combined into one notification document. The Director of Social Work provided training and education on the updated policy to Social Workers, Nursing Managers and Unit Clerks. 4. How will The New Jewish Home Sarah Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Social Work and/or designee will conduct audits monthly on the timely notification to the Office of State LTC ombudsman and provide a report of the audit findings to the QAPI committee monthly X 3 months then quarterly for action as appropriate. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details Based on record review and interview conducted during the recertification survey from 1/22/25 to 1/30/25, the facility did not ensure annual performance reviews for nursing staff were completed at least once every 12 months. Specifically, the facility was unable to provide annual performance reviews for 2 of 5 Certified Nurse Aides (#14, #16) reviewed. The findings are: The facility policy titled Human Resources - Performance Appraisals - Competencies, revised 12/14, documented: It is the policy of the New Jewish Home to routinely and periodically appraise the job performance and competencies of each employee. Performance appraisals will be performed after the completion of the probationary period for all non-exempt staff and after the initial review period for exempt staff. Each employee is evaluated annually thereafter. During an interview and observation on 1/27/25 at 9:54 AM the Director of Human Resources stated departments were responsible for completing annual performance appraisals for certified nurse aides. They stated the human resource department sent notifications and reminders via email and during morning reports. The Director of Human Resources stated they were unable to provide an annual performance appraisal for Certified Nurse Aides #14 and # 16. They stated they were not aware why an annual performance appraisal for Certified Nurse Aides #14 and #16 was not completed. During an interview on 1/29/25 at 10:54 AM the Administrator stated human resources attempted to complete staff performance appraisals annually. They stated there had been shortcomings in annual performance appraisals during 2023-2024 due to the human resource director position being a corporate shared role and not a dedicated role for the facility. 10NYCRR 415. 26 (c)(2)(iii) | Plan of Correction: ApprovedMarch 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the staff found to have been affected by the deficient practice is: The DON and/or designee will ensure that all nursing employees affected by the deficient practice receive an annual performance review for the period under review 2024. How will you identify other staff as having the potential to be affected by the same deficient practice what corrective action will be taken? The DON and/or designee will ensure that all nursing employees receive an annual performance review for the period under review 2024. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. A list of all C.N.As on all shifts will be distributed via email to all nurse managers and nursing supervisors to ensure that all requires nursing staff receive an annual performance review. All nursing supervisors will receive email notification to remind them that annual performance evaluations are due. DON and or designee will track and monitor compliance with completion of annual performance reviews for nursing staff. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) A tracking list will be utilized to validate that all evaluations are completed and submitted to HR. The tracking will be audited weekly x one month ,then monthly x three months. The results of the audits will be submitted to the Administrator and results of the audits will be reported to the QAPI committee monthly by the Director of Nursing for 3 months to the QAPI committee for action as appropriate |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the Recertification Survey from 1/22/2025-1/30/2025, the facility did not ensure each resident maintained, to the extent possible, acceptable parameters of nutrition and hydration status for one of two residents (Resident #163) reviewed for Nutrition. Specifically, for Resident #163 there was no documented evidence for the implementation of 960ml per day fluid restriction as per physician order. The finding is: The Policy & Procedure titled Nursing Intake and Output; Management of Fluid Restriction revised 12/2024 documented the purpose is to maintain an accurate record of resident's fluid intake and output with risk for dehydration or fluid overload. Procedure: Nurse initiates intake and output sheets and determines with the dietician the amount of fluids to be provided with meals, between meals, and with medications. The Dietician indicates on meal card Fluid Restriction, and monitors fluid provided at meals. The Certified Nurse Aide records intake and output and reports at the end of the shift. Resident #163 had [DIAGNOSES REDACTED]. The Physician order [REDACTED]. Nutritional Supplements 237 mililiters one time a day, fluid restrictions 960 milliliters a day 11-7 60 milliliters, 7-3 660 milliliters, 3-11 240 milliliters, and renal diet. The Annual Minimum Data Set (an assessment tool) dated 12/6/2024 documented Resident #163 had severely impaired cognition, and received [MEDICAL TREATMENT] while a resident The Resident Care Plan dated 12/20/24: Potential for Nutrition, Risk for altered Fluid Balance related to End Stage [MEDICAL CONDITION] documented fluid restriction with no specifics. During observation on 1/22/2025 at 12:30 PM, Resident #163 was observed eating lunch in their room. The meal tray was observed with coffee and juice. The resident's meal ticket on 1/23/25 did not document Resident #163 was on fluid restriction. There was no documented evidence in the electronic medical record for daily fluid ml's consumed During an interview on 1/27/25 at 12:22 PM, Registered Dietician #1 stated the resident was on fluid restriction related to [MEDICAL TREATMENT] as documented in the doctor order and medication administration record. Registered Dietician #1 stated the kitchen provided fluids based on the meal ticket and nurses should tally the amount taken in. They stated staff should know they could not go over the daily total amount fluid restriction and were unaware the resident meal ticket did not reflect fluid restriction. During an interview on 01/27/25 at 12:38 PM, Kitchen Supervisor #23 stated if the resident was on a fluid restriction it should be documented on the resident's meal tickets. They were unsure why Resident #163's meal ticket did not reflect the fluid restriction. During an interview on 01/27/25 at 12:42 PM, Certified Nurse Aide #10 stated Resident #163 liked coffee with meals and normally consumed 2 cups. They stated they documented the resident's fluid intake in the kiosk by percentage, not by the exact amount. They were unaware the resident was on a fluid restriction. They additionally stated if someone was on a fluid restriction the nurse would let them know in report and they would have a sheet on a clip board to fill out that would document the exact amount of fluid the resident consumed. During an interview on 01/27/25 at 12:49 PM, Licensed Practical Nurse #11 stated they were unaware the resident was on a fluid restriction. They stated when a resident was on fluid restriction, certified nurse aides usually documented intake on a clipboard. They stated nurses would normally document on the Medication Administration Record. During an interview on 01/27/25 at 01:27 PM, the Director of Nursing stated the meal ticket should have the fluid restriction documented on it. The nurse would know if someone was on a fluid restriction by reviewing the physician's orders [REDACTED]. They stated fluid restriction should also be included on the certified nurse aide task list. They stated residents on fluid restrictions should have intake and output documented on a separate sheet and nurses should be totaling fluid intake at the end of each shift to ensure the resident was compliant with fluid restriction. They stated they were unable to locate any Intake/output sheets for this resident. During an Interview on 01/28/25 at 08:47 AM, the Food Service Director/Dietician stated when a resident was put on fluid restriction the physician would put the order in place. They stated the dietician was responsible for ensuring the fluid restriction was written on the meal ticket. They stated the dietician should break down how much fluid should be provided from kitchen and nursing in the care plan. They stated the dietician should do meal rounds to ensure the resident was compliant with the ordered fluid restriction. They stated as dieticians they did not regularly check to see if the nursing staff was documenting intake and output. 10 NYC 415. 12(j) | Plan of Correction: ApprovedMarch 18, 2025 1. The Registered Dietitian responsible for the resident's care re-created a new meal ticket with the physician ordered fluid restriction transcribed onto the ticket. The Director of Food and Nutrition Services counseled the dietitian responsible for transcribing the fluid restriction order onto the meal ticket. All residents care plans were reviewed and updated. 2. The Food Service Management team and dietitians completed a facility -wide audit to identify all residents with a fluid restriction order. All meal tickets were then checked against the audit to ensure accurate entry of prescribed fluid restriction. 3. The Fluid Restriction Policy was reviewed to ensure compliance with F 692. All nursing, dietary, and food service employees received in-service training on the Fluid Restriction Policy. a. The Registered Dietician (RD) and Director of Food and Nutrition corrected meal tickets to reflect ordered fluid restrictions. b. All resident care plans and CNA task lists were reviewed and updated to ensure compliance with fluid restriction requirements. 4. The RD will generate and review daily fluid restriction reports 3 times a week to verify that: a. RD acknowledges Fluid Restrictions order in progress Note Section of the EMR. b. RD enters Fluid Restriction Order in Nutrition Care Plan c. Fluid Restriction appears on the TAR d. Fluid restriction allowances entered on Meal Ticket. The Registered Dietician/ Director of Food and Nutrition Services will report findings of the weekly audits to the QAPI committee monthly x three months for action as appropriate. The Director of Food and Nutrition Services is responsible for the corrective action. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey and abbreviated survey (NY 514) from 1/22/25 to 1/30/25, the facility did not ensure that each resident's right to privacy and confidentiality of their personal and medical records was maintained. Specifically, the health information of another resident was attached to Resident #535's discharge summary and given to Resident #535's designated representative. The findings are: The policy and procedure titled Health Information Privacy and Accountability Act Information Security Policy revised 1/26/2023 documented corporate information assets shall be protected whether the information is in oral, written, taped or electronic form. Corporate information assets shall be equally protected regardless of the nature of the asset and how and where it is transmitted or stored. Resident #535 was admitted to facility with the following [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] documented Resident #535 had modified independence in cognition. The 3/19/24 Discharge Summary note documented Resident #535 was discharged to the care of their family. Instructions given and understood. On 01/24/25 at 11:42 AM and 12:04 PM, the Administrator stated Resident #535's designated representative let them know they received the health information record of another resident and stated they did send the paperwork back to the facility but could not recall the resident's name and was unable to provide copies of the returned health information record. The Administrator stated the nurse that discharged Resident #535 printed the discharge summary, took the paperwork off the fax/copy machine and attached another resident's health information record to the discharge summary. 10 NYCRR 415. 3 (d)(1)(ii) | Plan of Correction: ApprovedMarch 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice? The documentation that was given in error was returned by the family member and given to the Administrator. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice? The discharge list for all residents scheduled for discharged will be reviewed daily and discharge documents double checked prior to preparing discharge. A two -person verification process will be put into place to ensure the privacy and confidentiality of all residents for discharge. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. To correct the deficient practice all staff clinical and non-clinical will receive training and education on the following policies HIPAA Information Security Policy ,HIPAA Internet and Intranet Use, and HR-Sanctions for Breach of HIPAA. The training and education will be coordinated by the ADON and/or designee. This training will also be provided on an annual basis and to all new hires and contract staff. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change.) An Audit of all discharged Residents will be completed 1 X week for 1 month by RN Supervisor or Designee, then Monthly X 3 months The data will be submitted to the DON and/or designee and results of audits will be reported to the QAPI Committee monthly by the Director of Nursing/Designee for 3 months for action as appropriate. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details Based on observation, record review, and interview during the recertification survey conducted 1/22/25 to 1/30/25, the facility did not ensure the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift was posted in a prominent place, readily accessible to residents and visitors on 3 of 6 days reviewed. Findings include: The daily resident census and nurse staffing information could not be located in a prominent place readily accessible to residents and visitors from 1/22/25 through 1/24/ 25. During an interview on 1/27/25 at 11:11 AM the Director of Nursing stated daily staffing reports were usually posted by the nurse manager on a table near front desk security. During an interview and observation on 1/27/25 at 11:42 AM Nurse Manager #27 stated they posted daily staffing information on a table at the front entrance near the security desk. The resident census and daily staffing schedule was observed in a plastic paper holder obscured by numerous other papers folded over the schedule. Nurse Manager #27 stated as placed, the staffing schedule was not visible to residents or visitors. During an interview on 1/29/25 at 10:54 AM the Administrator stated they were made aware that daily resident census and nurse staffing data was not visibly posted 1/22/24 to 1/24/ 25. They stated the daily resident census and nurse staffing data would be relocated to a visible bulletin board at the lobby entrance. 10 NYCRR 415. 13 | Plan of Correction: ApprovedMarch 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice : The deficient practice was corrected immediately by installing a locked bulletin board in the lobby of the facility to publicly display the daily resident census and nurse staffing information. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). All residents were affected by this deficient practice since the facility did not have the daily resident census and nurse staffing information in an area clearly visible to residents,patients and families. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. The DON and/or designee will ensure that the daily resident census and nurse staffing information is posted daily on each shift. All RN Nursing Supervision and Nurse Managers will be in-serviced on policy for posting daily resident census and nurse staffing information by the DON and/or designee. All newly hired supervisors/nurse managers will be in-serviced at the time of hire. All nursing management staff will receive annual inservice on completing and posting of the daily census and nurse staffing information. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change.) The Administrator and/or designee will audit the daily staffing and resident census posting daily for 2 weeks and then weekly for 1 month. Results of the audit will be reported to the QAPI committee monthly by the Administrator for 3 months for action as appropriate |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey and abbreviated survey (NY 310) conducted 01/22/25-01/30/25, the facility did not ensure residents received quality of care in accordance with professional standards of practice for 1 of 4 Residents (#534) reviewed for accidents. Specifically, timely assessment and treatment were not provided for Resident #534 who had a 5/24/24 unwitnessed fall that was not reported by Certified Nurse Aide #43 and Licensed Practical Nurse # 44. Subsequently, on 5/25/24 after bruising was noted on their back Resident #534 was transferred to the hospital where it was determined Resident #534 had a fractured scapula and fractured ribs #4,#5 and # 6. The findings are: The facility policy titled Resident Incident/Accident Reporting and Investigating Process revised 8/31/22 documented the responsibility of the employee is to notify a licensed nurse if they observe a resident who has sustained an accident/injury of unknown origin. The responsibility of the licensed nurse is to complete the exam of the resident with the injury of unknown origin and notify the nursing supervisor of the injury of unknown origin. Resident #534 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (an assessment tool) dated 3/20/24 documented Resident #534 had cognitive impairment, required moderate assistance for activities of daily living, used a wheelchair, did not have wandering behaviors and had a history of [REDACTED]. The Fall Risk Tool dated 3/10/24 documented Resident #534 was at risk for falls. The Comprehensive Care Plan dated 3/16/24 documented out of bed in common area while awake and restless. There was no evidence in the medical record that documented Resident #534 had an unwitnessed fall, the registered nurse supervisor, medical doctor or family were notified, an assessment was conducted. or that treatment was provided after the 5/24/24 fall. The Accident/Incident report dated 5/25/24 documented at 6:00 AM Licensed Practical Nurse #40 was informed by Certified Nurse Aide #41 of a bruise on the resident's back which was painful to touch and discovered while turning the resident on their side. There was no history of a fall. The nursing supervisor, physician and family were notified, and the resident was transferred to the hospital. Statements were obtained from staff but did not reveal a fall had occurred. On 5/28/24 a statement by Food Service Worker #42, documented they were coming from the bathroom and saw Resident #534 on the floor in the dining room. They called for help and were met but Certified Nurse Aide #43 who asked them for help to get the resident into the wheelchair. They helped the resident into the chair and Certified Nurse Aide #43 left the room with the resident The Accident/Incident report documented the Director of Nursing returned to question the staff again on 5/28/ 24. Certified Nurse Aide #43 at first denied a fall occurred then stated there was a fall and Licensed Practical Nurse #44 helped to get the resident off the floor without the nursing supervisor assessment. Licensed Practical Nurse #44 also denied a fall occurred but then stated they assisted Resident #534 off the floor with Certified Nurse Aide #43 and did not notify the nursing supervisor to report the fall or assess the resident for injuries. On 5/25/24 Resident #534 was sent to the hospital for evaluation of a large painful bruise on their back which the hospital determined to be fractured ribs #4,#5,#6 and an acute comminuted and displaced [MEDICAL CONDITION] right scapula. During an interview on 1/27/25 at 11:08 AM Certified Nurse Aide #43 stated they were on a computer and the licensed practical nurse told them someone was on the floor in the dining room and to get them off the floor.Certified Nurse Aide #43 stated Licensed Practical Nurse #44 did not make a report or inform the supervisor about the incident. During an interview on 1/27/25 at 1:05 PM Licensed Practical Nurse #44 stated they knew something was happening in the dining room and sent Certified Nurse Aide#43 in to see what was going on. They stated they saw Certified Nurse Aide #43 wheeling Resident #534 out of the dining room. Licensed Practical Nurse #44 stated they should have called the supervisor, but did not because they did not know if the resident slid to the floor or fell . Licensed Practical Nurse # 44 stated the resident should have been assessed by a registered nurse before being helped off the floor, During an interview on 1/27/25 at 11:56 AM the Director of Nursing stated they did an investigation to find out why the resident had a bruise and was in pain. They stated Certified Nurse Aide#43 told them there was no fall because they had been asked to help residents off the floor and didn't want to get the nurse in trouble. The Director of Nursing stated Certified Nurse Aide #43 told them they got the resident off the floor with Licensed Practical Nurse # 44. The Director of Nursing stated Certified Nurse Aide#43 and Licensed Practical Nurse#44 moved Resident#534 off the floor before an assessment was done and because the fall was not reported treatment was delayed until the next morning. During an interview on 1/30/25 at 11:11 AM Medical Doctor #47 stated they were the covering doctor who first saw the resident during the morning of 5/25/ 24. They stated there was right shoulder pain, some facial grimacing and swelling. They stated if they were made aware sooner the resident would have gone to the hospital sooner. Medical Doctor #47 stated they had many residents in the facility and their expectation was for nurses to assess and let them know of any issues. Medical Director #47 stated the physician was on call 24/ 7. Medical Doctor #47 stated they relied on the staff. During an interview on 1/29/25 at 4:35 PM Medical Doctor #46 (Primary Physician) stated the resident was at risk for falls and needed close monitoring. Medical Doctor #46 stated the resident often stood up from their wheelchair without assistance. Medical Doctor #46 stated the resident should not have been left alone in the dining room. Medical Doctor #46 stated the resident should have been assessed after the fall and should have gotten care after the fall. Medical Doctor #46 stated rib fractures are very painful. Medical Doctor #46 stated they expected a registered nurse would assess a resident after a fall. 10NYCRR 415. 12 | Plan of Correction: ApprovedMarch 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: To achieve correction for the resident found to be affected by the deficient practice in-services were provided to all licensed nurses that if observe a resident who has sustained an accident/injury of unknown origin they must promptly notify the nursing supervisor on duty. All staff will also receive mandatory training on the policy Resident Incident /Accident Reporting and Investigation Process 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). All residents have the potential to be affected by the same deficient practice. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. Policy was reviewed and found to be in compliance. Education to nursing staff regarding purpose of incident reporting. Appropriate and immediate interventions are implemented and corrective actions are taken to minimize negative outcomes and prevent reoccurrence. Incidents and accidents will be reviewed during nursing huddle to identify any missing responses to incidents. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur Audits will be done weekly X one month and Monthly X 3 months by Director of Nursing or Designee. All results from the audits completed will be reported to the QAPI committee X 3 months for action appropriate. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during Recertification and Abbreviated Survey (NY 858, NY 058) conducted from 01/22/25-1/30/25, the facility did not ensure that all alleged violations of abuse including injuries of unknown origin were reported immediately, but not later than 2 hours to the state survey agency for 2 of 3 residents reviewed for Abuse (Resident #110 and Resident#186). Specifically, 1) Resident #110 was noted to have a bruise on 10/27/24 that was not reported to the state agency until 10/30/ 24. and 2) Resident # 186 was noted to have a bruise on 1/12/25 that was not reported to the state agency until 1/16/ 25. The findings are: The facility policy titled Abuse, Neglect and Mistreatment Prevention dated 11/4/22 documented particularly for events that take place in nursing home or adult day health center - if during the course of the investigation, identifies that serious bodily injury has occurred and there is reasonable suspicion that abuse, neglect, mistreatment or exploitation is the cause, reports the situation within two hours to the state agency and local police precinct and fills out any forms required by the agency. 1) Resident # 110 had [DIAGNOSES REDACTED]. The 9/30/24 Quarterly Minimum Data Set documented Resident #110 had severely impaired cognition, verbal and physical behaviors exhiboted 1-3 days, and required substantial to maximal assist with all activities of daily living. The Investigation Report documented a bruise was reported to the floor nurse on 10/27/24, the supervisor was made aware on 10/28/24, and reported to the state agency on 10/30/ 24. During interview on 1/29/25 at 11:08 the Director of Nursing stated the injury of unknown origin was initially reported on 10/27/24, an investigation was initiated to include interviews, and the facility findings were inconclusive.They stated it was then reported to the Department of Health on 10/30/ 24. They stated they were on vacation at the time.The Director of Nursing stated they were aware of state agency reporting requirements of 2 hours. During interview on 1/29/25 at 12:01 PM the Medical Director stated although they could not conclusively rule out abuse the resident had a significant history of behaviors. The Medical Director stated the residents advanced age, fragile skin, behaviors, resistance to care, osteopenia, blood thinners and a malignancy put the resident at high risk for bruises.The Medical Director stated they were unaware the facility did not report the injury of unknown origin to the state agency in a timely manner. 2) Resident # 186 had [DIAGNOSES REDACTED]. The 11/15/24 Quarterly Minimum Data Set documented Resident #186 had severely impaired cognition, was dependent with activities of daily living and had one fall with injury. The 1/12/25 Incident Investigation documented the Licensed Practical Nurse went to Resident #186's room and noted a left forehead hematoma, left cheek 1x1 skin tear and discoloration to the left cheekbone. Resident #186 was unable to state how the incident occurred. The injury of unknown origin was reported to the state agency on 1/16/25 at 9:13 AM. During interview on 1/24/25 at 1:54 PM the Administrator stated they were aware injuries of unknown origin needed to be reported to the state agency within 2 hours. During interview on 1/28/25 at 3:00 PM the Director of Nursing stated the bruise was noted on 1/12/25, but was not reported to the state agency until 1/16/ 25. 10 NYCRR 415. 4(b)(2) | Plan of Correction: ApprovedMarch 10, 2025 What corrective action will be accomplished for those residents found to have been affected by the deficient practice? To correct the deficient practice we reviewed all incidents for the last 90 days and identified any incidents of abuse that were not reported timely. Staff member was disciplined for failing to report incident on 1/12/25 timely to the ADON on call. Staff will also be re-educated on purposeful rounding and monitoring skin integrity during the performance of ADLs. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the same deficient practice.All incident and accidents reports for the last 90 days were reviewed for timely reporting. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? The Policy was Reviewed and found to be in compliance. To prevent the deficient practice all staff members including clinical and non-clinical staff will receive training and education on reportable incidents and policies Patient Incident Management, and Abuse, Neglect, Mistreatment Prevention. This training will also include immediately reporting all alleged violations involving neglect ,abuse, including injuries of unknown origin. Nurse supervision will conduct frequent rounding each shift to ensure that residents are in safe environment and not subjected to abuse, neglect, and mistreatment. During the rounding nurse supervisor will remind staff that all allegation of abuse, incident of mistreatments, injuries of unknown origin should be promptly reported. An on-call monthly schedule for ADONs/DONs will be posted in the nursing office for call support to ensure all incidents are reported timely to the DOH. Nurse supervisor will contact on call nursing leadership to facilitate timely reporting of all allegations of abuse neglect, or mistreatment within two hours. It is responsibility of the DON and/or designee to ensure timely reporting all incidents involving injuries of unknown origin and allegations of abuse The training will be providing by the Nurse Educator and /or designee. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur? The DON, or designee, will review nursing shift report, nursing documentation, and clinical alerts to ensure any injuries are identified, properly investigated and reported to the appropriate people daily x 2 weeks and then weekly x 1 month and monthly thereafter. Results will be provided to QAPI for action as appropriate. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details Based on record review and interview conducted during the recertification survey from 1/22/25 to 1/30/25, the facility did not ensure certified nurse aides were provided required 12 hours of training to ensure safe delivery of care. Specifically, the facility was unable to provide evidence that 3 of 5 Certified Nurse Aides (#18 #20 and #21) reviewed for nurse aide in-service training were provided 12 hours of mandatory annual in-service training. The findings are: The Corporate Facility Policy titled, Continuing Education In-Service and Competence Training, (revised 11/4/24) documented In-service training must be sufficient to ensure the continuing competence of nurse aides but be no less than 12 hours per year. During an observation and interview on 01/27/25 at 02:07 PM the Nurse Educator, provided 6. 0 hours of in-service for Certified Nurse Aide #18, 6. 5 hours for Certified Nurse Aide #20, and 9 hours for Certified Nurse Aide # 21. The Nurse Educator stated Certified Nurse Aides #18, #20, and #21 did not complete 12 hours of annual in-service training. The Nurse Educator stated they had difficulties completing in-services for certified nurse aides due to technical difficulties that prevented the aides from completing in-services at nurse stations. During an interview on 01/29/25 at 10:54 AM the Administrator stated the facility had difficulty completing 12 hours of annual in-services due to staff time and technical issues. They stated certified nurse aides were requested to complete in-services while on duty and the unit workload often prevented certified nurse aides from having time to work on in-service completion. The Administrator stated technical issues resulted in the removal of the online in-service program from unit computers. The Administrator stated staff needed to complete online in-services on facility classroom computers which was difficult since staff did not have time to leave their unit during their shifts to complete in-services. 10NYCRR 415. 26 | Plan of Correction: ApprovedMarch 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: There were no residents affected by this deficient practice. To correct the deficient practice the Nurse Educator and/or designee will provide educational sessions twice weekly for certified nurse aides to meet the required twelve hours of mandatory annual inservice training. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). All residents have the potential to be affected by the deficient practice. The Nurse Educator and/or designee will generate a list of all certified nurse aides to track the staff required to receive the mandatory training and schedule employees. An audit of all current CNAs will be conducted to identify any staff who has not completed their 12 hours of annual in-service.o correct the deficient practice the Nurse Educator and/or designee will provide educational sessions twice weekly for certified nurse aides to meet the required twelve hours of mandatory annual inservice training. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. Training will be scheduled weekly one hour allotted for each training, and all attendance will be track and trended. Nurse Educator will address any issues with non-compliance with the DON and/or designee to ensure continuing competence of nurse aides mandatory requirement of twelve hours of training. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor the continued effectiveness of the systemic change.) The Director of Nursing and/or Designee will report the results of staff mandatory training to the QAPI Committee monthly by the Director of Nursing/Designee for 3 months to the QAPI committee for action as appropriate |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Recertification Survey from 01/22/2025 through 01/30/2025, the facility did not ensure residents had the right to a dignified dining experience for 3 of 35 sampled residents (Residents #585, #165, and #72). Specifically, Certified Nurse Assistant #17 and #21 referred to Resident #585 as a feeder during lunch service on 1/22/25, Certified Nurse Aide #36 was observed standing over Resident #165 while feeding them a lunch meal, and Certified Nurse Aide #37 was observed standing over Resident #72 while feeding them their meal. The findings include: The facility policy titled Nursing, Feeding of Residents Revised 5/21/14 documented the registered nurse will evaluate the resident needs for assistance with feeding and assign certified nurse assistants to assist with feeding accordingly. Communicates to the assigned certified nurse assistant resident need, preferences and limitation in process. Supervises the feeding process. Observes the feeding process. Resident #585 had [DIAGNOSES REDACTED]. The Care Plan dated 1/17/25 titled Impaired Cognitive Function/Dementia or impaired thought processes related to [MEDICAL CONDITION] with global [MEDICAL CONDITION] documented face the resident when speaking and make eye contact. During an observation on 01/22/25 at 12:37 PM, Certified Nurse Assistant #17 and #21 referred to Resident #585 as a feeder during lunch in front of other residents and staff present in the dining room. During an interview on 01/24/25 at 11:34 AM Certified Nurse Assistant #17 stated they were aware they referred to resident #585 as a feeder while conversing with another certified nurse assistant during the lunch meal on 1/22/25 at 12:37PM. They stated they were aware residents should not be referred to as feeders. They stated they should have obtained and used the residents name while conversing with another certified nurse assistant and assisting Resident # 585. During an interview on 01/28/25 at 12:10 PM Certified Nurse Assistant #21 stated they were aware they used the word feeder during lunch service on 1/22/25 at 12:37PM. They stated they did not know the residents should not be referred to as feeders. During an interview on 01/29/25 at 10:09 AM the Director of Nursing stated residents should be addressed by their preferred name during interactions with resident and discussions amongst staff. They stated referring to a resident as a feeder was unacceptable. Resident #165 was admitted with [DIAGNOSES REDACTED]. The Comprehensive Care Plan dated 9/11/23 titled Activities of Daily Living documented one staff assist for eating. The Quarterly Minimum (MDS) data set [DATE] documented Resident #165 had severe cognitive impairment and was dependent on staff for eating. During an observation on 1/22/25 at 12:24PM, Certified Nurse Aide #36 was observed feeding Resident #165 while standing and feeding them a peanut butter and jelly sandwich. During an interview on 1/22/25 at 12:27 PM Certified Nurse Aide #36 stated they were supposed to be seated next to the resident when assisting with meals but there were no chairs available. Resident #72 had [DIAGNOSES REDACTED]. The 11/22/24 Minimum Data Set (an assessment tool) documented the resident had severe cognitive impairment and required assistance with meals. The Comprehensive Care Plan dated 11/21/24 for Activities of Daily Living documented the resident will perform self-feeding with supervision. During an observation on 1/22/25 at 12:34PM Certified Nurse Aide #37 was observed standing over Resident #72 while feeding them their lunch meal. During an interview on 1/22/25 at 12:34 PM Certified Nurse Aide #37 stated they knew they were supposed to sit while they fed the resident. During an interview on 1/28/25 at 3:07 PM the Director of Nursing stated staff were supposed to sit next to residents while they assisted with meals. They stated staff should have conversations with residents during meals 10 NYCRR 415. 5(a) | Plan of Correction: ApprovedMarch 10, 2025 1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Residents were assessed and there were no signs of distress noted due to observed practice. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? An audit was completed by all unit nursing supervisors and/or designees to identify and create a list of all resident requiring assistance with eating. The facility will ensure that all resident in need of feeding assistance are not affected by this deficient practice by ensuring that all staff are educated on the rights of the residents and the responsibilities of the facility to properly care for all residents with dignity. The DON and/or designee will ensure that residents requiring assistance with eating are provided with the necessary assistance and staff communicates appropriately during the dining experience. This will be accomplished by conducting meal observations audits focused on residents requiring assistance at meal times. Audits will be reviewed to ensure that there has been no negative effects for residents requiring assistance with feeding i.e. weight loss, or resident intake is affected negatively. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? The policy and procedure was reviewed and staff education provided on the policy Nursing, Feeding of Residents, and Resident Rights. All nursing staff including RNs,LPNs and CNAs will receive in-service on the Residents Rights incorporating dignity, feeding and the dining experience. and the policy on Nursing Feeding of Residents with demonstration. This in-service will also be provided on an annual basis and new nursing employees at the time of hire. This in-service will also be provided to agency and contract staff. This training will be completed by the Nurse Educator and/or designee under the direction of the DON. Additional seating was provided for staff to ensure adequate seating in the dining room to assist residents with dining. 4. How will the corrective action be monitored to ensure the deficient practice will not recur? Each unit will be randomly audited 1 X per week by Nursing Supervisor or Designee to ensure residents have a dignified dining experience. All data will be submitted to the DON for analysis. Immediate problems observed during audits will be addressed and remediated to improve staff performance. The DON and/or designee will be responsible for ensuring that residents have a right to a dignified dining experience. The results of Audits will be reported to DON to be reported out at QAPI committee monthly X 3 months and quarterly thereafter for action as appropriate. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 30, 2025
Corrected date: N/A
Citation Details Based on record review and interview conducted during recertification and abbreviated survey (NY 240, NY 828 and NY 718)) from 1/22/25 to 1/30/25, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the staffing schedule from (MONTH) 22 2024 through (MONTH) 29 2025, the facility did not consistently provide adequate staffing on all units/shifts to meet the needs of the residents. The findings are: A facility policy titled, Nursing Staffing (reviewed 9/24), documented an adequate number of staff consistent with the organization's mission, the scope of services provided, and the population served. Staff is hired with the qualifications that commensurate with the defined job responsibilities and applicable degrees/certifications. The Director of Nursing in conjunction with the department of Human Resources and the Administration of the Home will ensure that the Department's staffing complement is continuously filled. Nurse minimum daily staffing: 7:00AM - 3:00PM shift: Units NE1, SW1: 2 nurses 5 certified nurse assistants. Units NE2 and SW2: 1. 5 nurses, 5 certified nurse assistants. Pavilion 2 unit: 2 nurses and 5 certified nurse assistants. Weinberg unit: 3 nurses and 5 certified nurse assistants. Weinberg Gardens Unit: 1 nurse and 3 certified nurse assistants. Small house Units 1,2, 3: 2 nurses and 3 advanced level aides. 3:00PM - 11:00PM shift: Units NE1, SW1: 1 nurse and 4 certified nurse assistants. Units NE2 and SW2: 1 nurse and 4 certified nurse assistants. Pavilion 2 unit: 1 nurse and 4 certified nurse assistants. Weinberg unit: 2 nurses and 4 certified nurse assistants. Weinberg Gardens Unit: 1 nurse and 3 certified nurse assistants. Small house Units 1,2, 3: 2 nurses and 3 advanced level aides. 11:00PM - 7:00AM shift: Units NE1, SW1: 1 nurse and 3 certified nurse assistants. Units NE2 and SW2: 1 nurse and 3 certified nurse assistants. Pavilion 2 unit: 1 nurse and 3 certified nurse assistants. Weinberg unit: 2 nurses and 3 certified nurse assistants. Weinberg Gardens Unit: 1 nurse and 2 certified nurse assistants. Small house Units 1,2, 3: 1 nurse and 1. 5 advanced level aides. The Nursing and Certified Nurse Assistant Assignment staffing assignment sheets from 12/22/24 through 1/29/25 documented the following dates in which the facility minimum staffing standards were not met: Northeast 1 unit, minimum staffing requirements of 5 certified nurse assistants was not met on the 7:00AM-3:00PM shift: 12/22/24, 12/24/24, 12/25/24,12/29/24, 12/31/24, 1/1/25, 1/3/25, 1/5/25, 1/13/25 and 1/25/25, minimum staffing requirements of 4 certified nurse assistants was not met for the 3:00PM-11:00PM shift.: 12/25/24, 12/29/24, 1/5/25 and minimum staffing requirements of 3 certified nurse assistants was not met for the 11:00PM-7:00AM shift:12/31/24, 1/1/25, 1/13/25, 1/2425 and minimum staff requirements of 2 nurses the 7:00AM-3:00PM shift was not met: 12/25/24, 12/26/25, 12/28/24, 1/1/25, 1/2/25, 1/3/25, 1/5/25, 1/8/25, /2/25, 1/3/25, 1/5/25, 1/8/25, 1/12/25, 1/13/25, 1/15/25, 1/21/25, 1/23/25, 1/25/25, 1/26/25, 1/27/25 and 1/28/25, Northeast 2 unit, minimum staffing requirements of 5 certified nurse assistants was not met on the 7:00AM-3:00PM shift: 12/22/24, 12/24/24, 12/25/24, 12/28/24 12/29/24, 12/31/24, 1/1/25, 1/4/25, 1/5/25, 1/13/25, minimum staffing requirements of 4 certified nurse assistants was not met for the 3:00PM-11:00PM shift.: 12/25/24, 12/29/24, 1/1/25, 1/4/25, 1/5/25, minimum staffing requirements of 3 certified nurse assistants was not met for the 11:00PM-7:00AM shift: 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/5/25, and minimum staff requirements of 1. 5 nurses were not met: 12/25/24, 1/2/25, 1/3/25, 1/5/25, 1/11/25, 1/13/25, 1/21/25, 1/25/25, 1/27/25 Pavilion 2 Unit, minimum staffing requirements of 5 certified nurse assistants was not met on the 7:00AM-3:00PM shift: 12/22/24, 12/24/24, 12/25/24,12/29/24, 12/31/24, 1/1/25, 1/2/25, 1/3/25, 1/4/25, 1/5/25, 1/25/25, 1/26/25, minimum staffing requirements of 4 certified nurse assistants was not met for the 3:00PM-11:00PM shift.: 12/27/24, 12/29/24, 1/5/25, minimum staffing requirements of 3 certified nurse assistants was not met for the 11:00PM-7:00AM shift: 12/27/24, 12/30/24, 12/31/24, 1/1/25, 1/2/25, 1/3/25, 1/4/25, 1/5/25, 1/7/25, 1/21/25, minimum staff requirements of 2 nurses for the 7:00AM-3:00PM was not met: 12/26/24, 1/2/25, 1/3/25, 1/5/25, 1/8/25, and minimum staff requirements of 2 nurses for the 11:00PM-7:00AM were not met: 1/25/ 25. Southwest 1 Unit, minimum staffing requirements of 5 certified nurse assistants were not met on the 7:00AM-3:00PM shift: 12/22/24, 12/30/24, 1/4/25, 1/5/25, 1/13/25, minimum staffing requirements of 4 certified nurse assistants were not met for the 3:00PM-11:00PM shift: 12/25/24, 1/5/25, 1/13/25, 1/26/25, 1/29/25, minimum staffing requirements of 3 certified nurse assistants were not met for the 11:00PM-7:00AM shift: 12/27/24, 12/31/24, 1/1/25, 1/3/25, 1/5/25, 1/13/ 25. and minimum staff requirements of 2 nurses were not met for the 7:00AM-3:00PM shift: 12/25/24, 12/29/24, 1/1/25, 1/3/25, 1/4/25, 1/5/25, 1/12/25, 1/13/25, 1/21/25, 1/25/25, 1/26/ 25. Southwest 2 Unit: minimum staffing requirements of 5 certified nurse assistants were not met on the 7:00AM-3:00PM shift: 12/22/24, 12/29/24, 1/4/25, 1/5/25, 1/26/25, minimum staffing requirements of 4 certified nurse assistants were not met for the 3:00PM-11:00PM shift: 12/25/24, 12/29/24, 1/5/25, 1/26/25, minimum staffing requirements of 3 certified nurse assistants were not met for the 11:00PM-7:00AM shift: 12/23/24, 12/30/24, 12/31/24, 1/21/25, 1/26/ 25. and minimum staff requirements of 1. 5 nurses were not met for the 7:00AM-3:00PM shift: 12/22/24, 1/2/25, 1/3/25, 1/13/25, 1/26/ 25. Weinberg Unit, minimum staffing requirements of 5 certified nurse assistants were not met on the 7:00AM-3:00PM shift: 12/26/24, 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/5/25, 1/9/25, 1/26/25, minimum staffing requirements of 4 certified nurse assistants was not met for the 3:00PM-11:00PM shift: 12/22/24, 12/29/24, 12/31/24, 1/4/25, 1/5/25, minimum staffing requirements of 3 certified nurse assistants were not met for the 11:00PM-7:00AM shift: 12/27/24, 12/31/24, 1/2/25, 1/3/25, 1/4/25, 1/8/25, 1/12/25, minimum staff requirements of 3 nurses were not met for the 7:00AM-3:00PM shift: 12/24/24, 12/25/24, 12/26/24, 12/27/24, 12/28/24, 12/29/24, 12/31/24, 1/2/25, 1/3/25, 1/5/25, 1/12/25, 1/25/25, 1/26/25, 1/27/25, 1/28/ 25. Weinberg Gardens Unit, minimum staffing requirements of 3 certified nurse assistants were not met on the 7:00AM-3:00PM shift: 12/22/24,12/28/24, 12/31/24, 1/5/25, 1/10/25, 1/11/25, 1/13/25, 1/26/25, 1/27/25 minimum staffing requirements of 3 certified nurse assistants were not met for the 3:00PM-11:00PM shift.: 12/22/24, 12/25/24, 12/27/24, 12/28/24, 12/30/24, 12/31/24, 1/1/25, 1/4/25, 1/5/25, 1/11/25, 1/25/25, 1/26/25 and minimum staffing requirements of 3 certified nurse assistants were not met for the 11:00PM-7:00AM shift: 12/31/ 25. Small House Unit 1, minimum staffing requirements of 3 advanced certified nurse assistants were not met on the 7:00AM-3:00PM shift: 12/22/24, 12/27/24, 12/28/24, 12/29/24, 12/30/24, 1/2/25, 1/4/25, 1/5/25, 1/6/25, 1/10/25, 1/11/25, 1/12/25, 1/16/25, 1/18/25, 1/19/25, 1/20/25, 1/24/25, 1/25/25, minimum staffing requirements of 2 advanced certified nurse assistants were not met for the 3:00PM-11:00PM shift:12/23/24, 12/24/24, 12/28/24, 1/2/25, 1/7/25, 1/11/25, 1/17/251/21/25, 1/23/25 and minimum staffing requirements of 1. 5 advanced certified nurse assistants were not met for the 11:00PM-7:00AM shift: 12/25/24, 1/23/ 25. Small House Unit 2, minimum staffing requirements of 3 advanced certified nurse assistants were not met on the 7:00AM-3:00PM shift: 12/22/24, 12/24/24, 12/25/24, 12/26/24, 12/27/24 12/28/24, 12/29/24, 12/30/24, 12/31/24, 1/1/25, 1/2/25, 1/4/25, 1/5/25, 1/10/25, 1/11/25, 1/12/25, 1/18/25, 1/19/25, 1/24/25, 1/25/ 25. minimum staffing requireme | Plan of Correction: ApprovedMarch 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice. The staffing schedules were reviewed to identify whether or not any units were adversely affected by the nursing staffing. There was no issue with worsening of wounds or care not provided to any residents. RN Supervisor or designee would ensure all care was provided. 2. How will The New Jewish Home Sarah Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The Facility acknowledges that all resident have the potential to be affected by this practice. Nursing and the HR team will work collaboratively to improve recruitment and retention efforts which may involve offering incentives ,agency staffing,and utilizing overtime. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. We will continue to work collaboratively with area nursing schools and C.N.A programs to improve our recruitment efforts. In 2024 we hired 140 direct care givers 82% were from Agencies. In 2025 we plan on having an open house,as well as expand our relationship with other staffing agencies. The nursing staffing policy will be updated by DON or designee to reflect minimum and maximum staffing numbers for each unit that supports resident safety. The Recruitment Manager and Nursing Leadership team will meet weekly to discuss vacancies and recruitment efforts. The recruitment manager/HR will an update on positions filled, and pending applicants for onboarding. The Recruitment Manager and or designee will track and trend recruitment efforts and present the data monthly. The Nursing staffing policy will be updated to reflect minimum and full complement staffing. 4. How will The New Jewish Home Sarah Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) Nursing staffing hours/numbers will be monitored daily by the DON and reported to the administrator. The DON and/or designee will submit data reports on the vacancy/position report and recruitment and retention activities monthly to the QAPI committee. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details Based on observation and staff interview the facility did not ensure that exhaust and grease filters were installed in accordance with NFPA 101 and NFPA 96. Specifically, an exhaust system and grease filters were not installed in the cafe area in the Weinberg building where cooking and deep frying were observed to occur. The findings are: During the life safety survey conducted on 1/30/25 at 12:30 PM, a tour of the Weinberg building was conducted and a tour of the cafe area revealed a deep fryer in use on the counter and an exhaust system was not installed above the deep fryer. In addition, an electric burner was observed in a separate area in the cafe. In an interview with the Director of Plant Operations at the time of the finding, the Director of Plant Operations stated that the deep fryer will be removed. 2012 NFPA 101: 19. 3. 2. 5. 1. 2011 NFPA 96: 4. 1 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The maintenance staff permanently removed all cooking equipment from the Caf?â?® that would require an approved exhaust system and grease filter installation in accordance with NFPA 96. The Administrator banned the cooking of food that could create grease laden vapors. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout for same deficiencies. No other deficiencies were found. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. All maintenance and caf?â?® staff will receive additional education and all participants will understand the life safety issues identified, with cooking food that produces grease laden vapors without the requirements of an approved exhaust system and grease filters in accordance with 2010 NFPA 96 12. 1. 2. 4. The Director of Maintenance has been assigned the responsibility for the education of staff and report the findings to the QAPI Committee for the period of six (6) months. The facility will check Caf?â?® for unapproved cooking equipment and cooking of food that produces grease laden vapors monthly. The Director of Maintenance will complete documentation in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101 Life Safety Code 7. 1. 6 Walking Surfaces in the Means of Egress 7. 1. 6. 1 General 7. 1. 6. 1. 1 Walking Surfaces in the means of egress shall comply with 7. 1. 6. 2 through 7. 1. 6. 4 7. 1. 6. 2 Changes in Elevation. Abrupt changes in elevation of walking surface shall not exceed 1/2 in ( 6. 3 mm). Changes in elevation exceeding 1/4 in ( 6. 3 mm) , but not exceeding 1/2 in. (13 mm) shall be beveled with a slope of 1 in 2. Changes in elevation exceeding 1/2 in (13 mm) shall be considered a change in level and shall be subject to the requirement of 7. 1. 7. 7. 1. 6. 3 Level. Walking surfaces shall comply with all of the following: (1) Walking Surfaces shall be nominally level. 7. 1. 10 Means of Egress Reliability. 7. 1. 10. 1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Based on observation and staff interview, the facility did not ensure that the means of egress was maintained in accordance with NFPA 101. Specifically, the pathway from an enclosed courtyard to the public way was not leveled. This affected 50 percent of of the emergency exit discharge from 2 of 3 resident buildings. The findings are: During the Life Safety recertification survey conducted on 1/30/25 at 11:20 AM, an examination of the exterior pathway from the emergency exits from the Weinberg Pavilion and the Nursing home revealed that the walking surface from the emergency exit to a public way was not leveled. The pathway was a grassy surface. In an interview with the Director of Plant Operations at the time of the finding, the Director of Plant Operations stated that the Administrator will be informed. 2012 NFPA 101: 19. 2, 7. 1. 6. 1, 7. 1. 6. 1. 1, 7. 1. 6. 2, 7. 1. 10. 1*, 7. 2. 3. 5. 1, 7. 7 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The Facility engaged a contractor to install a level walking surface from the identified courtyard emergency exit to a public way meeting the provisions of 7. 1. 7 with respect to changes in elevation shall be a hard packed all-weather travel surface. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout for same deficiencies. No other deficiencies were found. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. The Maintenance staff will continuously maintain the pathway from an enclosed courtyard to the public way, free of all obstructions or impediments to full instant use in the case of fire or other emergency. The Director of Maintenance or designee will utilize an audit tool monthly to verify the exterior egress pathways are of a hard packed all weather travel surface and are maintained. The audit tool will document the findings and report the audit findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI Committee on a monthly basis for 6 months, as well as correction plan if warranted. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details 2011 NFPA 70 National Electrical Code Article 400. 8 Uses not Permitted. Unless specifically permitted in 400. 7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure. Based on observation and staff interview the facility did not ensure that relocatable power taps and an extension cord were used in accordance with NFPA 70. Specifically, power strips were noted daisy chained to one another in the pharmacy storage room and an extension cord was observed in use in a resident room. These issues were noted in 2 of 3 resident buildings. The findings are: During the Life Safety recertification survey conducted on 1/30/25 and 1/31/25 between the hours of 9:30 AM and 3:00 PM, the following issues were noted: At 1:40 PM, a tour of the pharmacy storage room was conducted and it was observed that multiple power strips were daisy - chained to one another energizing the computer equipment in the room. In an interview with the Director of Plant Operations at the time of the finding, the Director of Plant Operations stated that the daisy - chain of multiple adapters will be removed. On 1/31/25 at 11:55 AM, a tour of the SW 1 unit revealed that an extension cord was attached to an artificial tree in resident room 108. In an interview with the maintenance staff member at the time of the finding, the maintenance staff member stated that the extension cord will be removed. 2012 NFPA 70: 400. 8 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 28, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is 1. The maintenance staff permanently removed the power strips from the Pharmacy storage room. 2. The maintenance staff permanently removed the power strips from the computer equipment in the room. 3. The maintenance staff permanently removed the extension cord from the SW 1 unit in resident room 108. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that residents, visitors and staff have the potential to be affected by this practice. The facility checked all areas for the same deficiency. Any power strips or extension deficiencies were immediately corrected. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. The facility reviewed and updated the Electrical Safety Policy and Procedures. All maintenance staff will receive additional education and all participants will understand the life safety issues identified during the facilitys survey and the importance of ensuring compliance with the Electrical Safety Policy and Procedures with particular emphasis on power strips and extension cord prohibitions. The Director of Maintenance has been assigned the responsibility for the education of staff and will provide education on life safety issues and provide additional education to the maintenance staff when power strip or extension cord issues have been identified. The facility Maintenance staff will check the facility for the improper use of power strips and extension cords monthly. The Director of Maintenance will utilize an audit tool to document any findings. Any issue identified with the use of power strips or extension cords will be immediately corrected. The Administration will review the appropriate sections of the facilities Electrical Safety Policy with the residents in the monthly Resident Council Meetings. The Administration will inform the and families of the appropriate sections of the facilities Electrical Safety Policy in our quarterly email to all families. The Administration will also add this information in the facilities Admission packet given to all new residents and families. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details Based on observation, documentation review and staff interview, the facility did not ensure that the required generator tests were performed in accordance with NFPA 101 and NFPA 110. Specifically, documentation for the current fuel quality test for the three generators were missing and not provided at time of survey. The findings are: During the Life Safety recertification survey on 1/30/25, at approximately 10:40 AM, documentation review of the facility generator logs revealed that evidence of current fuel quality tests for 3 of 3 generators for the year 2024 was missing and not provided at time of survey. In an interview with the Maintenance staff member on 1/31/25 at approximately 1:50 PM, the Maintenance staff member stated that the fuel quality reports could not be located and the vendor will be contacted. 2012 NFPA 101: 9. 1. 3, 9. 1. 3. 1 2010 NFPA 110: 8. 3. 8 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The facilities Emergency Generator Company will complete the required annual fuel test for all three Emergency Generators. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that residents have the potential to be affected by this practice. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. The annual fuel test for the Emergency Generators was updated in the established Preventive Maintenance & Scheduling program. All inspection results will be recorded in the building Records & Logs. All maintenance staff will receive additional education and all participants will understand the life safety issues identified, with the annual fuel testing requirements for the Emergency Generators. The Director of Maintenance has been assigned the responsibility for the education of staff and report the findings to the QAPI Committee for the period of six (6) months. The facility will check for the Emergency Generator inspections and testing monthly. The Director of Maintenance will complete documentation in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101 7. 10 Marking of Means of Egress. 7. 10. 1 General. 7. 10. 1. 1 Where Required. Means of egress shall be marked in accordance with Section 7. 10 where required in Chapters 11 through 43. 7. 10. 2 Directional Signs. 7. 10. 2. 1* A sign complying with 7. 10. 3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. Based on observation and staff interview, the facility did not ensure that directional signage was posted showing the direction of travel in accordance with NFPA 101. Specifically, directional signage was not posted within the enclosed courtyard leading to a public way from 2 of 3 buildings. The findings are: During the Life Safety recertification survey conducted on 1/30/24 at 11:20 AM, a tour of the enclosed courtyard from the emergency discharge exits from the Weinberg and Nursing home buildings revealed that the courtyard lacked directional signage leading to the public way. In an interview with the Director of Plant Operations at the time of the finding, the Director of Plant Operations stated that the signs will be posted. 2012 NFPA 101: 19. 2. 2. 2. 4, 7. 10. 1, 7. 10. 1. 1, 7. 10. 2. 1 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The maintenance staff will permanently install Exit Signage from the exit doors through the enclosed exterior courtyard ensuring clear identification and direction for egress in case of fire or emergency. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for same deficiency. No other deficiencies were found. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. All maintenance staff will receive additional education and all participants will understand the life safety issues with Exit signage in accordance with the requirements of NFPA 101, 2012 Edition section 7. 10. 1. 5. 1. The In-Service Coordinator has been assigned the responsibility for the education of staff This education will also be provided to all new Maintenance staff and will be reviewed when concerns are identified. The Director of Maintenance or designee will inspect all areas for Exit signs monthly and utilize an audit tool to document the findings and report the audit findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the audits to the QAPI committee on a monthly basis for 6 months, as well as correction plan if warranted. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details 2010 NFPA 72: 72 National Fire Alarm and Signaling Code 14. 2. 5. 5 Testing shall include verification that the releasing circuits and components energized or actuated by the fire alarm system are electrically monitored for integrity and operates intended on alarm. 14. 4. 5* Testing Frequencies Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14. 4. 5, or more often if required by the authority having jurisdiction. 14. 6. 3. 2 Upon request, a hard copy record shall be provided to the authority having jurisdiction. Based on observation, record review and staff interview, the facility did not ensure that all devices associated with the fire alarm system were maintained and tested annually in accordance with NFPA 101 and NFPA 72. Specifically, documentation that the hold open devices and the magnetic egress locks were tested annually was not provided at time of survey. The findings are: During the life safety recertification survey on 1/30/25 at 9:55 AM, documentation review of the facility's maintenance logs was conducted, and it was revealed that the fire alarm system was last serviced by the vendor on 12/5/2024 and 8/20/24 and the service reports did not include the testing of the magnetic fire /smoke barrier doors hold open devices and the magnetic delayed egress locks throughout the facility. In an interview with the Maintenance Director of the same day at approximately 11:30 AM, the Director of Plant Operations stated that the vendor will be contacted. 2012 NFPA 101: 19. 3. 4. 1, 9. 6. 1. 3, 9. 6. 1. 4 2010 NFPA 72: 14. 4. 5, 14. 6. 3. 2 10 NYCRR 415. 29 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The Director of Maintenance contacted the facility fire alarm inspection and testing vendor. The vendor was directed to provide the testing of the magnetic fire /smoke barrier doors hold open devices and the magnetic delayed egress locks throughout the facility. The vendor will issue a complete inspection and testing report and then semi-annually thereafter. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance reviewed all vendor inspection and testing company reports related to the fire alarm system. No other deficiencies were identified. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. The Director of Maintenance will review all inspection and testing reports for compliance with 2010 NFPA 72: 72 National Fire Alarm and Signaling Code 14. 2. 5. 5 The facility reviewed the Fire Alarm System Policy and updated it to include the testing of the magnetic fire /smoke barrier doors hold open devices and the magnetic delayed egress locks semi-annually. The policy also includes Documentation of all inspections, tests, and maintenance shall be maintained by the Maintenance Director. The Director of Maintenance or designee will utilize an audit tool to document the findings and report the audit findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI Committee on a monthly basis for 6 months, as well as correction plan if warranted. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details Based on documentation review and staff interview, the facility did not ensure that a completed formal risk assessment for the building system categories was conducted and documented in accordance with NFPA 99. Specifically, documentation of the facility risk assessment describing the facility's building system categories was not provided at time of survey. This affected 3 of 3 resident buildings. The findings are: During the life safety recertification survey on 1/30/25 at 9:30 AM, documentation review of the facility logs revealed that a completed Building Systems Risk assessment was missing and not provided at time of survey. In an interview with the Director of Plant Operations on 1/31/25, the Director of Plant Operations stated that the Building systems Risk assessment will be located. 2012 NFPA 101 2012 NFPA 99: 4. 1* 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The Administrator met with the multidisciplinary team which included the Director of Nursing, the Director of Physical Therapy and the Director of Maintenance. The team reviewed the risk category definitions in NFPA 99 and completed the annual assessment. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that residents have the potential to be affected by this practice. The worksheet is used to record the risk level for listed systems in a given area. Any changes in systems will generate a review of the worksheet. The worksheet will be reviewed and updated at least annually. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. The Administrator reviewed and updated the Facilities Risk Assessment Procedure Policy. Any changes in systems will generate a review of the worksheet. The multidisciplinary team will also conduct an annual review and update the NFPA 99 worksheet. The multidisciplinary team will complete documentation of any findings in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review the monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the results to the QAPI committee on a monthly basis for 6 months, as well as correction plan if warranted. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details Based on observation and staff interview, the facility did not ensure that the corridor doors to hazardous areas were able to resist the passage of smoke in accordance with NFPA 101. Specifically, the corridor doors to storage rooms was not able to resist the passage of smoke and or lacked self -closing devices. These issues were noted in 2 of 3 resident buildings. The findings are: During the Life Safety recertification survey conducted on 1/30/25 and 1/31/25 between the hours of 9:30 AM and 3:00 PM, a tour of the Weinberg building revealed that the soiled utility room on the South unit did not latch when tested to self - close and the wheelchair storage room within the Rehab room lacked self - closing device. The corridor door to the oxygen storage room in the Weinberg building did to latch when tested to self - close and latch. This same situation was observed to the clean linen room located in the nursing home on SW 2 second floor. On 1/31/25 at 11:25 AM, a tour of the Nursing Home revealed that the self - closing device to the soiled utility room on the third floor was in disrepair. This same situation was observed on the corridor door to the oxygen storage room on the on the South West 1 unit and the clean linen room located on South West 2. In an interview with the Director of Plant Operations on 1/30/25 at the time of the finding, the Director of of Plant Operations stated that the doors will be repaired. 2012 NFPA 101: 19. 3. 1. 1, 19. 3. 2. 1, 19. 3. 2. 1. 3, 7. 2. 1. 8, 8. 4, 8. 7. 1 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is 1. The maintenance staff adjusted the door to the Weinberg building soiled utility room on the South unit. The corridor door self-closes and positive latches. 2. The maintenance staff installed a self-closing device to the wheelchair storage room within the Rehab room. The door self-closes and positive latches. 3. The maintenance staff adjusted the door to the Weinberg building oxygen storage room. The corridor door self-closes and positive latches. 4. The maintenance staff adjusted the door to the SW2 clean linen room. The corridor door self-closes and positive latches. 5. The maintenance staff replaced the self-closing devices on the door to the Nursing Home soiled utility room on the 3rd floor. The corridor door self-closes and positive latches. 6. The maintenance staff replaced the self-closing devices on the door to the Nursing Home oxygen storage room on SW 1. The corridor door self-closes and positive latches. 7. The maintenance staff replaced the self-closing devices on the door to the Nursing Home clean linen room on SW 2. The corridor door self-closes and positive latches 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for same deficiencies. No other deficiencies were identified. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. All maintenance staff will receive additional education and all participants will understand the life safety issues identified, with the protection of Hazardous Areas ÔÇ£ Enclosure in accordance with NFPA [PHONE NUMBER]: 19. 3. 1. 1. The Director of Maintenance has been assigned the responsibility for the education of staff and report the findings to the QAPI Committee for the period of six (6) months. The facility will check hazardous area enclosure doors self-close and positive latch monthly. The Director of Maintenance will complete documentation in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted. |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details Based on observation and staff interview, the facility did not ensure that the illumination of the means of egress was installed in accordance with NFPA 101. Specifically, a light switch was observed to turn of the exterior lighting above the emergency exit door and lighting was not installed above the exit door. These issues were noted from 1 of 3 emergency exits from the Nursing Home building. The findings are: During the Life Safety recertification survey conducted on 1/30/25 and 1/31/25 between the hours of 9:30 AM and 3:00 PM, the following issues were observed: On 1/31/25 at approximately 12:00 PM, a tour of the Stairwell on South West 1 revealed that the wall mounted light switch turn off the lights above the emergency discharge exit door. In an interview with the maintenance staff member at the time of the finding, the maintenance staff member stated that the switch will be covered. At 12:05 PM the same day, an examination of the emergency discharge exit from the resident unit on South West 1 revealed that there was no light installed above the exit. In an interview with the maintenance staff member at the time of the finding, the maintenance staff member stated that the light fixture installed above the emergency exit on the building directly opposite the exit provides illumination from the exit. 2012 NFPA 101: 7. 8. 1. 1, 7. 8. 1. 2, 7. 8. 1. 3*, 7. 9. 2. 3* 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The maintenance staff will permanently install a dual lamp light fixture over the exterior of the exit door from the resident unit on South West 1 in accordance with the requirements of NFPA 101, 2012 Edition, Section 19. 2. 8 and 7. 8. The maintenance permanently removed the wall light switch for the egress lighting to South West 1 Stairwell. The required egress lights will not be switchable. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for same deficiencies. No other deficiencies were found. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. All maintenance staff will receive additional education and all participants will understand the life safety issues with lighting in the means of egress and egress lighting must be continuously on or automatic without manual intervention in accordance with the requirements of NFPA 101, 2012 Edition, Section 19. 2. 8 and 7. 8. The In-Service Coordinator has been assigned the responsibility for the education of staff This education will also be provided to all new Maintenance staff and will be reviewed when concerns are identified. The Director of Maintenance or designee will inspect all egress lighting monthly and utilize an audit tool to document the findings and report the audit findings to the QAPI Committee monthly for a period of six (6) months 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the audits to the QAPI committee on a monthly basis for 6 months, as well as correction plan if warranted. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details Based on observation and staff interview, the facility did not ensure that the trash chutes were maintained in accordance with NFPA 82. Specifically, the intake door to the linen chute did not positive latch upon testing. This was noted on 1 of 2 resident floors in the Nursing home. The findings include: During the Life Safety recertification survey conducted on 1/31/25 at 12:20 PM, a tour of the South west 2 second floor unit was conducted and it was observed linen chute intake door did not positive latch when tested to self close. In an interview with the maintenance staff member at the time of the finding, the maintenance staff member stated that the door will be repaired. 2012 NFPA 101: 19. 5. 4. 1; 9. 5. 2 2009 NFPA 82: 5. 2. 3. 3, 5. 2. 3. 3. 1, 5. 2. 3. 3. 1. 1 10 NYCRR 711. 2 (a)(1) | Plan of Correction: ApprovedFebruary 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The maintenance staff repaired the identified linen chute intake door on South West 2 second floor unit. The trash chute intake door self-closes and positive latches. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all intake chute doors throughout the facility for same deficiency. No other deficiencies were found. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. All maintenance staff will receive additional education and all participants will understand the life safety issues with chute intake doors must self-close and positive latch in accordance with the requirements of NFPA 82. The In-Service Coordinator has been assigned the responsibility for the education of staff This education will also be provided to all new Maintenance staff and will be reviewed when concerns are identified. The Director of Maintenance or designee will inspect all chute intake doors monthly and utilize an audit tool to document the findings and report the audit findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the audits to the QAPI committee on a monthly basis for 6 months, as well as correction plan if warranted. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details 2012 NFPA 101: 9. 7. 5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: 5. 2. 1. 1* Sprinklers shall be inspected from the floor level annually. 5. 2. 1. 1. 2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)*Loading (6) Painting unless painted by the sprinkler manufacturer 5. 2. 1. 1. 3* Any sprinkler that has been installed in the incorrect orientation shall be replaced. 5. 2. 1. 1. 4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation Based on observation, documentation review and staff interview the facility did not ensure that sprinklers were maintained in accordance with NFPA 25. Specifically, 1. The 5 - year internal pipe inspection was missing and not provided at time of survey, 2. Sprinklers in the kitchen were noted exhibiting signs of corrosion, and 3. A light bulb fixture obstructed the spray pattern of the sprinklers. The findings include: During the life safety recertification survey on 1/30/25 and 1/31/25 between the hour of 9:30 AM and 3:00 PM, the following issues were noted: On 1/30/25 at 9:30 AM documentation review of the facility sprinkler logs were conducted and it was noted that the 5 - year internal pipe inspection was missing and not provided at time of survey. In an interview with the Facility Project Manager on 1/31/25 at approximately 2:30 PM, the Facility Project Manager stated that the 5 - year internal pipe inspection was done and will locate the missing report. On 1/30/25 at approximately 2:10 PM, a tour of the kitchen was conducted and it was noted that 3 sprinklers in the pot washing area and a sprinkler where the hanging pots are stored exhibited signs of corrosion. In an interview with the Director of Plant Operations at the time of the finding, the Director of Plant Operations stated that the sprinklers will be replaced. On 1/31/25 at 12:15 PM, an examination of the telephone closet was conducted and it was observed that the light bulb in the room obstructed the spray pattern of the sprinkler. In an interview with Director of Plant Operations the time of the finding, the Director of Plant Operations stated that the light fixture will be repositioned. 2012 NFPA 101: 9. 7. 5 2011 NFPA 25: 5. 2. 1. 1*, 14. 2 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 21, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The facilities Certified Sprinkler Inspection and Testing Company completed the five (5) year sprinkler obstruction and internal valve inspection on 06/07/ 2022. The Certified Sprinkler Company will replace the identified 3 sprinkler pendants in the Kitchen. The maintenance staff will permanently relocate the identified light fixture in the Telephone closet to remove the obstruction to the sprinkler pendant. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that residents have the potential to be affected by this practice. The Director of Maintenance will review all sprinkler inspection and testing reports were completed and available for inspection by the Authority having jurisdiction at all times. The maintenance will survey the entire building for signs of corrosion of sprinkler pendants and obstructions to sprinklers. Any deficiencies identified will be corrected. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. All Maintenance staff will receive additional education and all participants will understand the life safety issues identified during the facilitys survey and the importance of ensuring compliance with the requirements of maintenance and proper installation of sprinklers 2012 NFPA 101: 9. 7. 5 and 2011 NFPA 25 5. 2. 1. 1. 2. The Director of Maintenance has been assigned the responsibility for the education of staff and report the findings to the QAPI Committee for the period of six (6) months The established Preventive Maintenance & Scheduling system will be followed reflecting the inspection and testing of the automatic sprinkler system as required by all codes, rules, and regulations. All inspection results will be recorded in the building Records & Logs and available for inspection by the Authority having jurisdiction at all times. The Director of Maintenance or Designee will inspect sprinklers monthly and record the results in the facilities Records & Logs. The Director of Maintenance will also complete documentation in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly sprinkler inspection audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of the sprinkler inspections to the QAPI committee on a monthly basis for 6 months, as well as correction plan if warranted. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2025
Corrected date: N/A
Citation Details Based on observation and staff interview, the facility did not ensure that the smoke barrier doors were maintained in accordance with NFPA 101. Specifically, the smoke barrier doors in smoke barrier walls were not able to resist the passage of smoke. This was noted between the smoke barrier doors in 2 of 3 resident buildings. The findings are: During the Life Safety recertification survey conducted on 1/30/25 and 1/31/25 between the hours of 9:30 AM and 3:00 PM, the following issues were noted: On 1/30/25, it was observed that the smoke barrier doors in smoke barrier walls were not able to resist the passage of smoke. An opening was observed between the two sets of smoke barrier doors. This was noted in the Weinberg Pavilion and the NH building. In an interview with the Director of Plant Operations at the time of the finding on 1/30/25 at 12:10 PM, the Director of Plant Operations stated that the doors are checked monthly and will be adjusted to close. 2012 NFPA 101: 19. 3. 7. 9, 8. 3. 4. 4 10 NYCRR 711. 2 (a) | Plan of Correction: ApprovedFebruary 28, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is The maintenance will staff install fire rated door extensions to permanently reduce the center gap opening to less than 1/8?Ø to the identified smoke barrier doors in the Weinberg and Nursing Home buildings. 2. How will The New Jewish Home(NAME)Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above). The facility acknowledges that all residents have the potential to be affected by this practice. The Director of Maintenance inspected all areas throughout the facility for same deficiencies. No other deficiencies were identified. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur. All maintenance staff will receive additional education and all participants will understand the life safety issues identified, smoke barrier doors. The Director of Maintenance has been assigned the responsibility for the education of staff and report the findings to the QAPI Committee for the period of six (6) months. The facility will check that all smoke barrier doors will prevent the passage of smoke monthly. The Director of Maintenance will complete documentation in an audit tool and report the findings to the QAPI Committee monthly for a period of six (6) months. 4. How will The New Jewish Home(NAME)Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e. - what program will monitor thee continued effectiveness of the systemic change.) The Director of Maintenance or Designee will review monthly audits for any cases of non-compliance. The Director of Maintenance or Designee will report the result of these audits to the QAPI committee on a monthly basis, as well as correction plan if warranted. |