Inspection Reports for
The New Jewish Home, Manhattan
120 W 106th St, New York, NY 10025, United States, NY, 10025
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Inspection Report — Nov 8, 2024
Complaint Investigation State
Date: Nov 8, 2024
Visit Reason
State-compiled facility profile showing 15 inspections from June 2022 to May 2026 with citation and enforcement history.
Complaint Details
The state logged 467 complaints about this facility; 17 led to on-site inspections. The facility received 114.7 complaints per 100 beds versus a statewide rate of 57.4, resulting in 6 citations from those complaints.
Findings
Across 15 inspections, 5 resulted in citations totaling 32 deficiencies, including both standard health and Life Safety Code violations. The facility had multiple enforcement actions and complaints, with citations ranging from no harm to immediate jeopardy.
Citations (27)
Free From Abuse And Neglect: Standard Health Citation for quality of care involving actual harm to residents.
Resident Rights/exercise Of Rights: Standard Health Citation for quality of care with minor potential harm.
Right To Be Free From Physical Restraints: Standard Health Citation for quality of care involving actual harm.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation for quality of care with minor potential harm.
Free Of Accident Hazards/supervision/devices: Standard Health Citation for quality of care with minor potential harm.
Infection Prevention & Control: Standard Health Citation for quality of care with minor potential harm.
Label/store Drugs And Biologicals: Standard Health Citation for quality of care with minor potential harm.
Medicaid/medicare Coverage/liability Notice: Standard Health Citation for quality of care with potential for minimal harm.
Reporting Of Alleged Violations: Standard Health Citation for quality of care with minor potential harm.
Electrical Systems - Essential Electric System: Life Safety Code Citation for NFPA requirements with minor potential harm.
Electrical Systems - Maintenance And Testing: Life Safety Code Citation for NFPA requirements with minor potential harm.
Hazardous Areas - Enclosure: Life Safety Code Citation for NFPA requirements with minor potential harm.
Portable Fire Extinguishers: Life Safety Code Citation for NFPA requirements with minor potential harm.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation for NFPA requirements with minor potential harm.
Requirements Before Submitting A Request For: Standard Health Citation for quality of care with no harm potential.
Activities Meet Interest/needs Each Resident: Standard Health Citation for quality of care with minor potential harm.
Behavioral Health Services: Standard Health Citation for quality of care with minor potential harm.
Free Of Accident Hazards/supervision/devices: Standard Health Citation for quality of care involving immediate jeopardy.
Investigate/prevent/correct Alleged Violation: Standard Health Citation for quality of care with minor potential harm.
Pasarr Screening For Md & Id: Standard Health Citation for quality of care with minor potential harm.
Responsibilities Of Providers; Required Notif: Standard Health Citation for quality of care with no harm potential.
Safe/clean/comfortable/homelike Environment: Standard Health Citation for quality of care with minor potential harm.
Safe/functional/sanitary/comfortable Environ: Standard Health Citation for quality of care with minor potential harm.
Self-determination: Standard Health Citation for quality of care with minor potential harm.
Building Rehabilitation: Life Safety Code Citation for NFPA requirements with minor potential harm.
Smoking Regulations: Life Safety Code Citation for NFPA requirements with minor potential harm.
Reporting - National Health Safety Network: Standard Health Citation for quality of care with minor potential harm not yet corrected.
Report Facts
Inspections on page: 15
Total violations/deficiencies cited: 32
Inspections with violations: 5
Inspections without violations: 10
Total complaints: 467
On-site complaint inspections: 17
Citations issued from complaints: 6
Enforcement actions: 6
Total fines: 34000
Inspection Report — Nov 7, 2024
Annual Inspection CMS
Date: Nov 7, 2024
Visit Reason
The inspection was conducted as a Recertification Survey from 10/31/2024 to 11/07/2024 to assess compliance with Medicare/Medicaid regulations and facility policies.
Findings
The facility was found deficient in multiple areas including failure to provide timely notice of Medicare non-coverage to residents' representatives, failure to timely report suspected abuse or neglect, unsafe storage of chemicals and medications, improper food storage with expired items, and inadequate infection prevention practices including lack of annual water management plan review and failure to maintain enhanced barrier precautions during intravenous medication administration.
Citations (6)
Failure to ensure residents or their representatives were provided timely notice of Medicare non-coverage on the same day as telephone notification.
Failure to timely report suspected abuse, neglect, or injuries of unknown source to the New York State Department of Health.
Failure to maintain a resident environment free from accident hazards; housekeeping cart containing chemicals was left unattended with door ajar and keys in lock.
Failure to ensure medication cart was locked and under direct observation of authorized staff.
Failure to store, prepare, distribute, and serve food in accordance with professional standards; expired food items found in walk-in refrigerator and emergency food storage.
Failure to provide and implement an infection prevention and control program; no annual review of water management plan and failure to maintain enhanced barrier precautions during intravenous medication administration.
Report Facts
Residents reviewed for Beneficiary Notification: 38
Residents reviewed for Accidents: 38
Residents affected by Medicare non-coverage notification deficiency: 2
Residents affected by abuse/neglect reporting deficiency: 2
Units observed for housekeeping cart hazard: 13
Units with medication cart storage deficiency: 1
Expired tortillas observed: 2
Expired canned food observed: several
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #8 | Nurse | Observed not wearing gown during intravenous medication administration requiring enhanced barrier precautions |
| Registered Nurse #7 | Unit Nursing Supervisor | Interviewed regarding failure of RN #8 to wear gown during intravenous medication administration |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control practices and medication cart locking standards |
| Director of Minimum Data Set & Managed Care | Director of Minimum Data Set & Managed Care | Interviewed regarding Medicare non-coverage notification process |
| Account Receivable Manager | Account Receivable Manager | Interviewed regarding mailing of Notice of Medicare Non-Coverage |
| Administrator | Administrator | Interviewed regarding responsibilities for providing and mailing Notice of Medicare Non-Coverage |
| Registered Nurse #4 | Registered Nurse | Interviewed regarding unwitnessed fall and injury of Resident #188 |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Interviewed regarding investigation summary of Resident #212 fall |
| Housekeeper | Housekeeper | Observed and interviewed regarding housekeeping cart left unlocked and unattended |
| Assistant Director of Environmental Services | Assistant Director of Environmental Services | Interviewed regarding housekeeping cart safety and key control |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed and interviewed regarding unlocked medication cart |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding medication cart locking procedures |
| Food Service Director | Food Service Director | Interviewed regarding expired food items and food safety practices |
| Director of Maintenance | Director of Maintenance | Interviewed regarding water management plan review |
Inspection Report — Mar 16, 2024
Abbreviated Survey CMS
Date: Mar 16, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to investigate allegations of abuse, neglect, and mistreatment of residents at the facility.
Complaint Details
The visit was complaint-related, triggered by allegations of abuse and neglect involving Residents #1 and #11. The facility investigation and video surveillance confirmed neglect and abuse occurred. Staff interviews and video evidence supported substantiation of the complaint.
Findings
The facility failed to treat residents with dignity and respect, resulting in neglect and abuse. Resident #11 was left on the floor without clothing for an extended period, and Resident #1 was physically restrained and left naked in a dining room for hours. The facility acknowledged abuse and neglect occurred and took investigative and corrective actions.
Citations (3)
Failure to treat Resident #11 with respect and dignity, leaving them on the floor without clothing for 35 minutes.
Failure to protect Resident #1 from abuse by restraining them with tables and holding their hands, leaving them naked and restrained for over two hours.
Failure to ensure Resident #1 was free from physical restraints unless medically necessary.
Report Facts
Residents reviewed: 20
Duration Resident #11 left on floor: 35
Duration Resident #1 restrained: 141
MDS Brief Interview of Mental Status score: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Named in findings related to neglect and abuse of Residents #1 and #11, including restraining Resident #1 and failing to assist Resident #11. | |
| Registered Nurse #1 | Named in findings related to failure to immediately assess Resident #11 and maintain their dignity. | |
| Registered Nurse Supervisor #1 | Assessed Resident #11 after extended time on floor; involved in follow-up and investigation. | |
| Licensed Practical Nurse #1 | Observed Resident #1 restrained and naked; took photos with personal phone; involved in investigation. | |
| Director of Nursing | Director of Nursing | Reviewed video evidence, acknowledged abuse and neglect, and participated in investigation. |
| Assistant Administrator | Assistant Administrator | Discovered video evidence during routine surveillance and initiated investigation. |
| Administrator | Administrator | Notified of incident, reviewed video, contacted law enforcement. |
| Nurse Practitioner #1 | Nurse Practitioner | Examined Resident #1 post-incident and reported no physical or psychosocial harm. |
Inspection Report — Oct 26, 2023
Annual Inspection CMS
Date: Oct 26, 2023
Visit Reason
The inspection was a recertification survey conducted from 10/16/2023 to 10/26/2023 to assess compliance with regulatory requirements for The New Jewish Home, Manhattan.
Findings
The facility was found deficient in multiple areas including resident rights and self-determination, environment safety and cleanliness, timely reporting of abuse, PASARR screening, activities programming, smoking safety, behavioral health care, medication storage, and food storage. Immediate Jeopardy was identified related to unsafe smoking practices but was removed after corrective actions.
Citations (10)
Failure to promote resident self-determination and support resident choice, evidenced by Resident #294 not being assisted to eat breakfast or brush teeth out of bed as preferred.
Failure to ensure a safe, clean, comfortable, and homelike environment, including broken plaster, rusty radiators, loose ceiling tiles, dirty wheelchairs, and stained feeding equipment in multiple units.
Failure to timely report suspected abuse and neglect to the New York State Department of Health within 2 hours, evidenced by delayed reporting of alleged abuse to Resident #79.
Failure to ensure PASARR screening for mental disorders or intellectual disabilities prior to admission for Resident #738.
Failure to provide ongoing activities to meet residents' needs, evidenced by Residents #25, #252, and #366 not receiving meaningful or adequate activities.
Failure to ensure adequate supervision and assistive devices to prevent accidents related to smoking, with unsafe smoking practices by Residents #162, #243, and #336 resulting in Immediate Jeopardy.
Failure to ensure all drugs and biologicals were safely stored and firmly affixed in the medication refrigerator, with a Schedule IV controlled substance vial stored on a movable shelf.
Failure to ensure food was stored in accordance with professional standards, with undated and unlabeled food in pantry refrigerators and temperatures above 41°F.
Failure to ensure a safe, functional, sanitary, and comfortable environment, with disrepair and water damage in the Library Room and outdoor Patio/Garden including broken furniture and warped wood.
Failure to ensure necessary behavioral health care and services to attain or maintain residents' highest practicable well-being, evidenced by inadequate intervention for Resident #25's anxiety and depression.
Report Facts
Residents sampled: 39
Residents reviewed for abuse: 10
Residents reviewed for PASARR: 40
Residents reviewed for activities: 6
Staff in-serviced on smoking policy: 429
Staff total: 597
Smoking hours: 12
Pantry refrigerator temperature: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW #1 | Social Worker | Responsible for completing Smoking Safety Evaluations and counseling residents on smoking policy |
| CNA #3 | Certified Nursing Assistant | Named in failure to assist Resident #294 with breakfast and oral hygiene |
| RN #5 | Registered Nurse | Interviewed regarding Resident #294's preferences and care |
| DON | Director of Nursing | Interviewed regarding abuse reporting and smoking incident |
| TRD | Therapeutic Recreation Director | Interviewed regarding activities programming and resident preferences |
| MD | Medical Director | Interviewed regarding psychiatry consults and psychology referrals |
| Psychiatrist | Interviewed regarding Resident #25's behavioral health care | |
| LPN #10 | Licensed Practical Nurse | Interviewed regarding medication refrigerator shelf |
| Director of Pharmacy | Interviewed regarding medication storage and inspections | |
| RNM #2 | Registered Nurse Manager | Interviewed regarding medication storage |
| DFN | Director of Food and Nutrition | Interviewed regarding food storage and labeling |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding pantry refrigerator temperature |
| CNA #22 | Certified Nursing Assistant | Interviewed regarding activities for Resident #366 |
| TR #1 | Therapeutic Recreation Aide | Interviewed regarding activities for Resident #366 |
| RNM #1 | Registered Nurse Manager | Interviewed regarding activities for Resident #366 |
| CNA #17 | Certified Nursing Assistant | Interviewed regarding activities for Resident #252 |
| LPN #9 | Licensed Practical Nurse | Interviewed regarding activities for Resident #252 |
| RNM #2 | Registered Nurse Manager | Interviewed regarding activities for Resident #252 |
| TRA #2 | Therapeutic Recreation Aide | Interviewed regarding activities for Resident #252 |
| AA | Assistant Administrator | Interviewed regarding smoking incident for Resident #162 |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding Resident #162 smoking |
| SG #1 | Security Guard | Interviewed regarding smoking monitoring |
| SW #2 | Social Worker | Interviewed regarding behavioral health support |
| DSW | Director of Social Work | Interviewed regarding behavioral health and psychology referrals |
Inspection Report — Dec 23, 2021
Annual Inspection CMS
Date: Dec 23, 2021
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints without proper orders or assessments, lack of resident and family participation in care planning, failure to provide professional standards of care such as catheter care and medication administration, inadequate activities programming for non-English speaking residents, failure to provide medically related social services such as appropriate clothing, medication errors related to improper medication concentration and labeling, and infection control deficiencies including improper storage of nebulizer equipment and oxygen tubing touching the floor. Additionally, the facility lacked a completed environmental risk assessment for Legionella.
Citations (8)
Use of physical restraints (hand mitten) without assessment, care planning, physician's order, or documentation.
Failure to involve residents and representatives in developing comprehensive care plans.
Failure to provide catheter care and ensure medication administration met professional standards.
Failure to provide activities meeting resident interests, especially for non-English speaking residents.
Failure to provide medically related social services including appropriate clothing and functioning television.
Significant medication error: resident prescribed Acetylcysteine 20% was given 10% concentration.
Drugs and biologicals not labeled or stored per manufacturer's recommendations (open vial of Acetylcysteine not dated or refrigerated).
Infection prevention and control deficiencies including improper storage of nebulizer mask, oxygen tubing and nebulizer tubing observed on floor, Foley catheter tubing touching floor, and lack of completed environmental risk assessment for Legionella.
Report Facts
Residents reviewed: 40
Residents sampled: 35
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #7 | Registered Nurse | Administered incorrect concentration of Acetylcysteine and failed to label opened vial properly |
| CNA #9 | Certified Nursing Assistant | Used hand mitten on resident without orders, stated family requested use |
| RN #9 | Charge Nurse | Observed resident with hand mitten but failed to follow restraint protocol |
| RN Manager | Registered Nurse Manager | Unaware of hand mitten use and stated restraint procedures |
| ADNS | Assistant Director of Nursing | Unaware of hand mitten use, stated facility is restraint free |
| LMSW | Licensed Master Social Worker | Assigned social worker for resident, stated not responsible for inviting resident to care plan meetings |
| DSW | Director of Social Work | Described care plan meeting invitation process |
| DON | Director of Nursing | Described care plan meeting invitation process |
| SDCC&QA | Senior Director of Clinical Compliance & QA | Confirmed care plan meeting invitation practices |
| LPN #6 | Licensed Practical Nurse | Interviewed regarding catheter care responsibility |
| RN #1 | Registered Nurse | Observed improper nebulizer storage |
| LPN #1 | Licensed Practical Nurse | Observed oxygen tubing touching floor |
| LPN #2 | Licensed Practical Nurse | Observed oxygen tubing touching floor |
| RN #4 | Nurse Manager | Observed oxygen tubing touching floor |
| ADON/ICN #3 | Assistant Director of Nursing/Infection Control Nurse | Described infection control training and procedures |
| LPN #3 | Licensed Practical Nurse | Observed oxygen tubing touching floor and described infection control training |
| RN #3 | Registered Nurse | Described lack of physician orders for catheter care |
| Social Worker #13 | Social Worker | Addressed resident's TV and clothing issues |
| CNA #6 | Certified Nursing Assistant | Described resident's resistiveness to care and clothing condition |
| Recreational Leader #16 | Recreational Leader | Described resident's activity preferences and TV issues |
| TR Leader #2 | Therapeutic Recreation Leader | Described assessment of resident's interests and language barrier |
| DML | Director of Meaningful Life | Described therapeutic recreation assessment process |
| Attending Physician #3 | Physician | Stated no orders are written for catheter care |
| Medical Director | Medical Director | Stated nurses are expected to follow catheter care policy without physician orders |
| Administrator | Administrator | Stated Legionella risk assessment maintained by Facility Operations Director |
| Facility Operations Director | Facility Operations Director | Stated no completed environmental risk assessment for Legionella |
| Assistant Administrator | Assistant Administrator | Stated facility did not complete environmental risk assessment for Legionella but would ensure one is done |
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