Sarah Neuman Center For Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Mamaroneck, New York.
- Location
- 845 Palmer Avenue, Mamaroneck, New York 10543
- CMS Provider Number
- 335296
- Inspections on file
- 24
- Latest survey
- October 23, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Sarah Neuman Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Two residents sustained injuries after being transferred without proper adherence to care plans and facility policy. In one case, a resident was transferred using a Hoyer lift by a CNA and an unauthorized private aide, resulting in a head hematoma when a safety strap failed. In another case, a resident was manually transferred by a single CNA without the required Sara lift or second staff member, leading to knee pain and swelling. Both incidents involved staff who were aware of the correct procedures but did not follow them, resulting in actual harm.
The facility did not convene a QAPI meeting or conduct a risk assessment after being cited for deficiencies, and failed to implement the required Directed Plan of Correction by the deadline set by the State Agency.
A resident with dementia, behavioral disturbances, and severely impaired cognition repeatedly refused ADL care, was non-compliant with redirection, and exhibited combative behaviors over several months. Despite ongoing documentation of these behaviors, staff did not initiate a behavior care plan until much later, contrary to facility policy requiring timely care plan updates by the IDT.
A resident with dementia, legal blindness, and a history of falls was left alone in the bathroom by a CNA, despite care plans requiring one-person assistance for toileting. The resident, who was resistant to care and cognitively impaired, fell while attempting to dress, sustaining a head injury. Facility documentation and staff interviews confirmed the need for supervision, but no care plan addressed the resident's resistance to care prior to the incident.
A resident with severe cognitive impairment was pushed by a CNA, causing the resident to stumble backward. The incident was witnessed by an RN Supervisor, who reported that the CNA justified the action by stating the resident did not listen. The facility's investigation confirmed the abuse, as the CNA did not deny the action, violating the facility's abuse prevention policy.
The facility did not perform required generator tests as per NFPA standards, with missing documentation for fuel quality tests for all three generators. A Maintenance staff member confirmed the absence of these reports and indicated that the vendor would be contacted.
The facility did not ensure annual testing of all fire alarm system devices, specifically the magnetic fire/smoke barrier doors' hold open devices and magnetic delayed egress locks, as required by NFPA standards. This was discovered during a life safety recertification survey, and the Director of Plant Operations confirmed the oversight.
The facility did not provide a completed formal risk assessment for building system categories as required by NFPA 99 during a life safety recertification survey. This affected all three resident buildings, and the Director of Plant Operations acknowledged the missing documentation, stating it would be located.
The facility did not comply with NFPA 101 standards as the emergency exit pathway from the Weinberg Pavilion and Nursing Home was not level, consisting of a grassy surface. This affected 50% of the emergency exit discharge from two of three resident buildings. The Director of Plant Operations acknowledged the issue.
A Life Safety recertification survey revealed that the facility did not comply with NFPA 101 standards for directional signage. The enclosed courtyard, used as an emergency discharge route from the Weinberg and Nursing home buildings, lacked signs indicating the direction to a public way. This deficiency was noted during a tour, and the Director of Plant Operations confirmed the absence of the signage.
The facility did not ensure that corridor doors to hazardous areas could resist smoke passage, as required by NFPA 101. During a survey, it was found that several doors, including those to soiled utility rooms and oxygen storage rooms, either did not latch or lacked self-closing devices. These issues were confirmed by the Director of Plant Operations.
The facility did not ensure proper illumination of an emergency exit as required by NFPA 101. A light switch was found to control the exterior lighting above an emergency exit door, and no light was installed directly above the exit. Illumination was instead provided by a light fixture on the building opposite the exit.
The facility was found non-compliant with NFPA standards as a deep fryer was in use without an exhaust system in the cafe area of the Weinberg building. The Director of Plant Operations confirmed the absence of the required system.
During a Life Safety recertification survey, the facility was found to be non-compliant with NFPA 70 due to daisy-chained power strips in the pharmacy storage room and an extension cord in use in a resident room. These issues were observed in two of three resident buildings, and staff interviews confirmed the improper use of electrical cords.
The facility did not ensure the trash chutes were maintained according to NFPA 82 standards. During a Life Safety recertification survey, it was found that the intake door to the linen chute on the second floor did not positive latch when tested to self-close. This issue was confirmed by a maintenance staff member.
The facility failed to maintain its sprinkler systems as per NFPA 25 standards. The 5-year internal pipe inspection report was missing, and sprinklers in the kitchen showed signs of corrosion. Additionally, a light bulb fixture obstructed a sprinkler's spray pattern. These issues were acknowledged by facility management.
The facility did not maintain smoke barrier doors to resist smoke passage, as observed in two resident buildings during a Life Safety survey. An opening was found between the doors, compromising their effectiveness. The Director of Plant Operations confirmed that the doors are checked monthly and will be adjusted.
A facility failed to provide adequate supervision and follow care plans, resulting in injuries to four residents. One resident, with a history of falls, was left unattended and sustained fractures. Another resident was improperly transferred, leading to a head injury. A third resident, requiring two-person assistance, was left with a single aide, resulting in a bruise. These incidents highlight significant lapses in care and supervision.
The facility failed to maintain adequate nursing staff, impacting resident care. Staffing schedules showed consistent shortages across various units and shifts, with residents reporting delays in care. The staffing coordinator and DON cited staff call-outs and high turnover as primary barriers, despite using temporary agencies and offering incentives. The Administrator acknowledged longer call bell response times due to staffing issues.
The facility failed to provide a dignified dining experience for three residents. CNAs referred to a resident as a 'feeder' and stood over two residents while feeding them, contrary to policy. The residents had conditions requiring meal assistance, and the care plans specified respectful assistance, which was not followed.
A facility failed to maintain resident privacy when a nurse mistakenly attached another resident's health information to a discharge summary given to a resident's representative. The error was discovered when the representative reported receiving the incorrect information. The resident involved had diagnoses of Diabetes, Hypertension, and Muscle Weakness.
The facility failed to report injuries of unknown origin for two residents to the state agency within the required two-hour timeframe. A resident with heart failure and dementia was found with a bruise, reported late due to the DON's absence. Another resident with dementia and a history of cancer had unexplained injuries, also reported late. Both incidents reflect non-compliance with timely reporting policies.
A resident with Anemia, Coronary Artery Disease, and Hypertension was transferred to the hospital due to vomiting and diarrhea. The facility failed to provide written notification of the transfer to the resident's representative and the Ombudsman, as required. The Director of Social Work admitted that notices were only sent if the resident was admitted to the hospital, not for emergency room visits.
A resident was transferred to the hospital without receiving a written notice of the facility's bed hold policy, as required by the facility's procedures. The Director of Social Work acknowledged that notifications were not sent if residents were sent to the emergency room and returned without hospital admission.
A resident with a history of falls was not assessed or treated in a timely manner after an unwitnessed fall. The CNA and LPN involved did not report the incident, leading to a delay in treatment. The resident was later found to have sustained serious injuries, including fractured ribs and scapula.
The facility failed to maintain infection control practices, lacking a documented water management plan for Legionella and failing to ensure staff adhered to PPE protocols. An environmental service worker entered a contact isolation room without proper PPE or hand hygiene, despite the resident being on contact precautions for Clostridium difficile.
A facility failed to develop a comprehensive care plan for a resident admitted to hospice care. The resident, with severe cognitive impairment and multiple diagnoses, was accepted onto hospice care, but no care plan was documented. A RN Supervisor admitted responsibility, citing their absence from work as the reason for the oversight.
A resident with End Stage Renal Disease was not provided with the necessary fluid restriction as ordered by the physician. The facility failed to document and communicate the fluid restriction, resulting in the resident's meal ticket lacking this critical information. Staff interviews revealed a lack of awareness and adherence to the facility's policy on managing fluid restrictions, leading to the deficiency.
A facility failed to provide consistent assessment and oversight for a resident receiving dialysis, as required by professional standards. The resident's dialysis treatments were not consistently documented, with missing pre and post-dialysis notes. Facility staff were unaware of the need for documentation from the dialysis center, and communication between the facility and the dialysis center was poor, leading to inadequate monitoring of the resident's condition.
The facility did not complete annual performance reviews for two CNAs, as required by policy. The Director of HR stated that departments were responsible for these appraisals, with reminders sent via email and morning reports. However, the appraisals were not completed, and the Administrator cited shortcomings due to the HR director role being a corporate shared position.
The facility did not ensure that the daily resident census and nurse staffing information were posted in a prominent place accessible to residents and visitors on three of six days reviewed. The information was obscured by other papers, making it not visible, as confirmed by interviews with the DON and a Nurse Manager. The Administrator acknowledged the issue and planned to relocate the data to a visible bulletin board.
The facility did not ensure certified nurse aides completed the required 12 hours of annual in-service training. Three aides received fewer hours than mandated due to technical difficulties and workload issues, as acknowledged by the Nurse Educator and Administrator.
The facility did not submit MDS assessments within the required timeframe for two residents. The assessments were completed but not transmitted due to an unknown change in status in the medical record. The MDS Coordinator acknowledged the oversight, and the DON was unaware of the delay.
A resident with Alzheimer's disease alleged that a CNA threw towels at them and yelled for them to say 'please' when they requested assistance. The CNA left without completing care, and the incident was not reported by the LPN. The facility's investigation found the CNA did not deny the allegations, leading to a conclusion of abuse.
Two residents experienced delayed reporting of abuse allegations in an LTC facility. In one case, an LPN failed to assess and report a resident's head injury promptly. In another, a resident alleged a CNA threw a towel at them, but the incident was not reported immediately, allowing the CNA to continue their shift. Both incidents were reported to the Department of Health later than required.
Failure to Prevent Accidents Due to Improper Transfers and Inadequate Supervision
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that residents received adequate supervision to prevent accidents, as evidenced by two separate incidents involving two residents. In the first incident, a resident with a history of cerebrovascular accident, severe cognitive impairment, and total dependence for transfers was transferred using a Hoyer lift by a certified nurse aide and a private aide who was not authorized or trained to provide clinical care. During the transfer, a safety strap on the lift became loose, causing the resident to strike the back of their head on a piece of furniture, resulting in a hematoma. The certified nurse aide involved had received training on the proper use of mechanical lifts and was aware of the requirement for two trained staff to perform such transfers, but allowed an untrained private aide to assist, contrary to facility policy and the resident's care plan. In the second incident, another resident with cellulitis and bilateral knee osteoarthritis, who was care planned and ordered to be transferred via Sara lift with two staff assistance, was transferred by a single certified nurse aide without the use of the mechanical lift. The aide did not use the Sara lift because a required lift pad was missing and decided to transfer the resident manually, despite knowing the resident required two-person assistance and mechanical support. As a result, the resident's knee struck the metal part of the bed, leading to swelling, redness, warmth, and complaints of pain. The aide acknowledged violating the care plan and physician order, and the resident continued to experience pain following the incident. Both incidents were confirmed through record review and staff interviews, which revealed that staff were aware of the facility's policies and the residents' care requirements but failed to follow them. The involvement of unauthorized personnel in direct care and the failure to use required mechanical devices and adequate staff assistance directly contributed to the residents sustaining injuries. These deficiencies resulted in actual harm to both residents, though the situation was not classified as Immediate Jeopardy.
Failure to Convene QAPI Meeting and Implement Directed Plan of Correction
Penalty
Summary
The facility failed to take actions aimed at performance improvement by not convening a Quality Assessment and Assurance (QAPI) meeting to address quality deficiencies identified during a previous survey. After the survey exited, the facility did not systematically identify, report, track, investigate, or analyze the cited deficient practice. The last QAPI meeting was held prior to the survey, and no subsequent meeting was convened within the required timeframe after receiving the statement of deficiencies. Additionally, the facility did not conduct a risk assessment to determine the causes of non-compliance. The facility also did not complete or implement the Directed Plan of Correction imposed with a Category 1 remedy by the deadline set by the State Agency. The Administrator confirmed that no QAPI meeting had been held to address the negative findings due to the Director of Nursing being on vacation. There was no evidence that the facility addressed or implemented the required corrective actions as directed by the State Agency.
Failure to Initiate Behavior Care Plan for Resident with Dementia and Behavioral Disturbances
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address behavioral issues for one resident with a history of dementia, behavioral and mood disturbances, and severely impaired cognition. Despite multiple documented instances where the resident resisted or refused activities of daily living (ADL) care, was verbally abusive, non-compliant with redirection, and exhibited uncooperative and combative behaviors, there was no evidence that a behavior or resistive-to-cares care plan was in place prior to late March. Progress notes over several months detailed repeated refusals of care, non-compliance, and safety concerns related to the resident's actions. Interviews with facility staff confirmed that the responsibility for initiating and updating care plans lies with the nurse managers. The nurse manager assigned to the unit was new and had not yet identified or initiated a care plan for the resident's behavioral issues, despite ongoing documentation of such behaviors. The lack of a timely and appropriate care plan was not in accordance with the facility's policy, which requires the interdisciplinary team to review and update care plans at least quarterly and as needed based on the resident's condition.
Resident Left Unsupervised in Bathroom Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of falls, dementia with behavioral and mood disturbances, legal blindness, and impaired balance was left alone in the bathroom by a Certified Nurse Aide (CNA), despite care plans indicating the need for one-person assistance with toileting and transfers. The resident, who was known to be resistant to care and had severely impaired cognition, was observed by the CNA through a slightly open bathroom door. While attempting to put on underpants, the resident placed both legs in the same leg hole and, while trying to pull the sliding bathroom door, fell backwards, resulting in an abrasion and bleeding to the posterior scalp. Facility documentation and staff interviews confirmed that the resident required supervision and touching assistance for toileting due to high fall risk and cognitive impairment. The CNA reported that the resident refused care and insisted on privacy, leading the CNA to leave the resident alone but attempt to monitor them visually. There was no evidence of a care plan addressing the resident's resistance to care prior to the incident. The Director of Nursing stated that the resident should never be left alone in the bathroom due to their unsteady gait and high risk for falls, and that staff were aware of this requirement.
Resident Abuse Incident by Certified Nurse Aide
Penalty
Summary
The facility failed to ensure that residents were free from abuse, neglect, or mistreatment, as evidenced by an incident involving a severely cognitively impaired resident. On the specified date, a Registered Nurse Supervisor observed a Certified Nurse Aide pushing the resident in the hallway, causing the resident to stumble backward. The Certified Nurse Aide justified their actions by stating that the resident did not listen, which was not an acceptable reason for physical contact. The resident involved in the incident had a history of severe cognitive impairment and required supervision for various activities, including eating, bed mobility, transfers, and ambulation. The resident's care plan indicated a risk for harm and abuse due to their cognitive condition and mood disorders. Despite these documented risks, the Certified Nurse Aide's actions were not in line with the facility's policy on abuse prevention, which mandates that residents must not be subjected to abuse by anyone. The facility's internal investigation confirmed the abuse allegation, as the incident was witnessed by the Registered Nurse Supervisor. The Certified Nurse Aide did not deny the action and was subsequently suspended pending further investigation. The facility's policy clearly states that residents have the right to be free from abuse, and the actions of the Certified Nurse Aide were in direct violation of this policy.
Plan Of Correction
Plan of Correction: Approved March 28, 2025 1. What corrective actions(s) will be accomplished for those residents found to have been affected by the deficient practice Resident #1 was assessed immediately to ensure that there were no injuries and emotional support was provided by RN Supervisor. A complete skin check was completed on resident #1 with no abnormal findings. Resident #1 was evaluated by the Social Worker and was unable to recall the incident due to severe cognitive impairment. Resident #1 also did not display any sign or symptoms of emotional distress. A psychology consult was also ordered for Resident #1 who was unable to recall the event and unable to engage in therapeutic interaction. Social worker has and will continue to follow up with resident to provide emotional support. Resident #1 was monitored for behavioral changes. No behavioral changes were noted. 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 this deficient practice. The Director of Social Services and/or designee will review and update care plans addressing the risk for Abuse for all residents with behavioral and/or cognitive impairment. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? To ensure the deficient practice will not recur, the Director of Nursing and/or designee will review the policy on Abuse/Neglect/Mistreatment- Prevention, Assessment & Reporting of these or other crimes against a resident/client in our care. Staff training and education will be provided to all staff on Abuse, Mistreatment Prevention. This education will focus on the facility responsibility to protect the resident rights and ensure residents remain from abuse. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put in practice The Director of Nursing and/or will perform random audits a total of five staff interviews weekly x 1 month and then bi-weekly x two weeks, and then monthly to ensure ongoing compliance. The Director of Social Work will perform random audits a total of five residents interviews weekly x 1 month, and then bi-weekly x two weeks, and then monthly to ensure ongoing compliance. All findings will be reported to the QAPI Committee by the Director of Nursing on a monthly basis.
Missing Generator Fuel Quality Test Documentation
Penalty
Summary
The facility failed to ensure that the required generator tests were performed in accordance with NFPA 101 and NFPA 110 standards. During a Life Safety recertification survey, it was observed that documentation for the current fuel quality tests for all three generators for the year 2024 was missing. This deficiency was identified during a documentation review of the facility's generator logs. In an interview, a Maintenance staff member confirmed that the fuel quality reports could not be located and mentioned that the vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved February 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 the 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.
Failure to Test Fire Alarm System Devices Annually
Penalty
Summary
The facility failed to ensure that all devices associated with the fire alarm system were maintained and tested annually in accordance with NFPA 101 and NFPA 72 standards. During a life safety recertification survey, it was observed that the facility's maintenance logs did not include documentation of annual testing for the magnetic fire/smoke barrier doors' hold open devices and the magnetic delayed egress locks. The last recorded service by the vendor occurred on two occasions in 2024, but these reports did not cover the required testing of these specific devices. This deficiency was confirmed during an interview with the Director of Plant Operations, who acknowledged the oversight and indicated that the vendor would be contacted to address the issue.
Plan Of Correction
Plan of Correction: Approved February 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 the 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.
Missing Building Systems Risk Assessment
Penalty
Summary
The facility failed to ensure that a completed formal risk assessment for the building system categories was conducted and documented in accordance with NFPA 99 standards. During a life safety recertification survey, it was discovered that documentation of the facility's risk assessment describing the building system categories was missing and not provided. This deficiency affected all three resident buildings within the facility. An interview with the Director of Plant Operations revealed that the risk assessment was not readily available, and the Director stated that it would be located.
Plan Of Correction
Plan of Correction: Approved February 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 the 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.
Non-compliance with NFPA 101: Uneven Emergency Exit Pathway
Penalty
Summary
The facility failed to maintain the means of egress in accordance with NFPA 101 standards, specifically regarding the walking surfaces in the means of egress. During a Life Safety recertification survey, it was observed that the pathway from the emergency exits of the Weinberg Pavilion and the Nursing Home to a public way was not level, as required by the code. The pathway consisted of a grassy surface, which did not meet the standard for a nominally level walking surface. This deficiency affected 50 percent of the emergency exit discharge from two out of three resident buildings. The Director of Plant Operations acknowledged the finding and indicated that the Administrator would be informed.
Plan Of Correction
Plan of Correction: Approved February 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 the 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.
Lack of Directional Signage in Emergency Exits
Penalty
Summary
During a Life Safety recertification survey, it was observed that the facility failed to ensure proper directional signage in accordance with NFPA 101 standards. Specifically, the enclosed courtyard, which serves as an emergency discharge route from the Weinberg and Nursing home buildings, lacked directional signage leading to a public way. This deficiency was identified during a tour of the courtyard, where it was noted that 2 out of 3 buildings did not have the required signage. The Director of Plant Operations acknowledged the absence of the signs during an interview conducted at the time of the survey.
Plan Of Correction
Plan of Correction: Approved February 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 the 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.
Deficiencies in Corridor Door Smoke Resistance
Penalty
Summary
The facility failed to ensure that corridor doors to hazardous areas were able to resist the passage of smoke as required by NFPA 101 standards. During a Life Safety recertification survey, it was observed that the soiled utility room door on the South unit of the Weinberg building did not latch when tested for self-closing. Additionally, the wheelchair storage room within the Rehab room lacked a self-closing device. Similar issues were noted with the corridor door to the oxygen storage room and the clean linen room in the nursing home on the SW 2 second floor. On a subsequent tour, the self-closing device to the soiled utility room on the third floor was found to be in disrepair, and the same issue was observed with the corridor door to the oxygen storage room on the South West 1 unit and the clean linen room on South West 2. These deficiencies were confirmed during an interview with the Director of Plant Operations.
Plan Of Correction
Plan of Correction: Approved February 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 SW1. 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 SW2. 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 – 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 the 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.
Deficient Illumination of Emergency Exit
Penalty
Summary
The facility failed to ensure proper illumination of the means of egress in accordance with NFPA 101 standards. During a Life Safety recertification survey, it was observed that a wall-mounted light switch could turn off the exterior lighting above an emergency exit door in the Stairwell on South West 1. Additionally, there was no light installed directly above the emergency discharge exit from the resident unit on South West 1. Instead, illumination was provided by a light fixture installed on the building directly opposite the exit. These deficiencies were noted in 1 of 3 emergency exits from the Nursing Home building.
Plan Of Correction
Plan of Correction: Approved February 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 the 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.
Non-compliance with Exhaust System Installation
Penalty
Summary
The facility failed to ensure compliance with NFPA 101 and NFPA 96 standards regarding the installation of exhaust and grease filters. During a life safety survey, it was observed that the cafe area in the Weinberg building had a deep fryer in use on the counter without an exhaust system installed above it. Additionally, an electric burner was noted in a separate area of the cafe. This deficiency was identified through both observation and staff interview, where the Director of Plant Operations acknowledged the absence of the required exhaust system and stated that the deep fryer would be removed.
Plan Of Correction
Plan of Correction: Approved February 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 Café 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 café 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 Café 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 the 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.
Improper Use of Electrical Cords in Facility
Penalty
Summary
The facility was found to be non-compliant with the 2011 NFPA 70 National Electrical Code Article 400.8 during a Life Safety recertification survey. Specifically, surveyors observed that power strips were daisy-chained together in the pharmacy storage room to energize computer equipment. Additionally, an extension cord was found in use in a resident room, connected to an artificial tree. These deficiencies were noted in two out of three resident buildings. Interviews with the Director of Plant Operations and a maintenance staff member confirmed the improper use of electrical cords and the intention to address the issues.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 [ROOM NUMBER]. 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 facility’s 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 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 the 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.
Linen Chute Door Fails to Latch Properly
Penalty
Summary
The facility failed to maintain the trash chutes in accordance with NFPA 82 standards. During a Life Safety recertification survey, it was observed that the intake door to the linen chute on the second floor of the southwest unit did not positive latch when tested to self-close. This deficiency was noted on one of the two resident floors in the nursing home. A maintenance staff member confirmed the issue during an interview at the time of the finding.
Plan Of Correction
Plan of Correction: Approved February 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 the 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.
Deficiencies in Sprinkler System Maintenance and Inspection
Penalty
Summary
The facility failed to maintain its automatic sprinkler and standpipe systems in accordance with NFPA 25 standards, as observed during a life safety recertification survey. The survey revealed that the 5-year internal pipe inspection report was missing and not provided at the time of the survey. During an interview, the Facility Project Manager acknowledged that the inspection had been completed but could not locate the report. This lack of documentation indicates a failure in maintaining proper records of required inspections. Additionally, during a tour of the kitchen, it was noted that three sprinklers in the pot washing area and a sprinkler where hanging pots are stored showed signs of corrosion. This condition was confirmed by the Director of Plant Operations, who stated that the sprinklers would be replaced. Furthermore, an examination of the telephone closet revealed that a light bulb fixture obstructed the spray pattern of a sprinkler, which was also acknowledged by the Director of Plant Operations. These findings highlight deficiencies in the maintenance and inspection of the facility's fire protection systems.
Plan Of Correction
Plan of Correction: Approved February 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 facility’s 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 the 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.
Smoke Barrier Doors Not Maintained
Penalty
Summary
The facility failed to maintain smoke barrier doors in accordance with NFPA 101 standards, as observed during a Life Safety recertification survey. Specifically, the smoke barrier doors in two of the three resident buildings, namely the Weinberg Pavilion and the NH building, were unable to resist the passage of smoke due to an opening between the two sets of doors. This deficiency was identified during the survey conducted on January 30 and 31, 2025. During an interview on January 30, 2025, the Director of Plant Operations acknowledged the issue, stating that the doors are checked monthly and will be adjusted to close properly.
Plan Of Correction
Plan of Correction: Approved February 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 staff will install fire rated door extensions to permanently reduce the center gap opening to less than 1/8” 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 the 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.
Inadequate Supervision and Care Plan Violations Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for four residents, leading to accidents and injuries. Resident #534, with a history of falls and cognitive impairments, was left unattended in a dining room, resulting in a fall that caused fractured ribs and a scapula. Despite multiple previous falls, the resident's care plan was not adequately updated to prevent further incidents. Staff failed to notify the nursing supervisor or physician immediately after the fall, delaying necessary medical assessment and treatment. Resident #70, who required a mechanical lift and two-person assistance for transfers, was improperly transferred by a single Certified Nurse Aide using a sit-to-stand device, contrary to the care plan. This resulted in the resident striking their head and sustaining a bruise. The incident was not reported to the nursing supervisor in a timely manner, and the care plan was not followed, leading to the resident's injury. Resident #207, who required two-person assistance for transfers and had a history of combative behavior, was left in the care of a single Certified Nurse Aide. This deviation from the care plan resulted in the resident sustaining a bruise on their forehead. The facility's investigation concluded that the injury was due to a violation of the care plan, as the resident was not provided the required level of assistance during care.
Plan Of Correction
Plan of Correction: Approved February 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 resident’s 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 resident’s 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 resident’s 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 staff’s 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? Audit 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 the 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.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by a review of staffing schedules and interviews conducted during a recertification and abbreviated survey. The staffing schedule from December 22, 2024, through January 29, 2025, revealed that the facility did not consistently provide adequate staffing on all units and shifts. The facility's policy on nursing staffing, which was reviewed in September 2024, required an adequate number of staff consistent with the organization's mission and the population served. However, the facility did not meet its minimum staffing requirements on numerous occasions across various units and shifts. Interviews with residents and staff highlighted the impact of staffing shortages on resident care. One resident reported inconsistent wound care due to insufficient nursing staff, while another resident experienced delays in call bell response and toileting assistance, attributing these issues to short staffing. The staffing coordinator acknowledged the challenges in meeting minimum staffing requirements, citing staff call-outs and a high turnover rate, particularly among registered nurses, as primary barriers. Despite efforts to use temporary staffing agencies and offer incentives for extra shifts, the facility struggled to maintain adequate staffing levels. The Director of Nursing and the Administrator both confirmed the facility's difficulties in meeting staffing requirements. The Director of Nursing noted that temporary agency staff were used to fill gaps, but cancellations and retirements among permanent staff exacerbated the issue. The Administrator expressed concern over longer call bell response times due to short staffing, although they emphasized the staff's commitment to providing quality care. The facility's inability to consistently meet staffing requirements affected the timely delivery of care and resident well-being.
Plan Of Correction
Plan of Correction: Approved March 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 residents 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 provide 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 the 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.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents during the recertification survey. Certified Nurse Assistants (CNAs) #17 and #21 referred to a resident as a 'feeder' during lunch service, which was acknowledged as inappropriate by the CNAs and the Director of Nursing. This incident occurred in the presence of other residents and staff, highlighting a lack of respect for the resident's dignity. Additionally, CNAs #36 and #37 were observed standing over two residents while feeding them, contrary to the facility's policy that requires staff to be seated when assisting residents with meals. The residents involved had various medical conditions, including dysphagia, cognitive impairments, and other chronic illnesses, necessitating assistance with eating. The care plans for these residents specified the need for respectful and appropriate assistance during meals, which was not adhered to by the staff. The Director of Nursing confirmed that staff should sit next to residents and engage in conversation during meals, which was not observed in these instances.
Plan Of Correction
Plan of Correction: Approved March 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 residents requiring assistance with eating. The facility will ensure that all residents 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.
Breach of Resident Health Information Privacy
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records during a recertification survey and abbreviated survey. Specifically, the health information of another resident was mistakenly attached to the discharge summary of Resident #535 and given to Resident #535's designated representative. This breach occurred when the nurse responsible for discharging Resident #535 printed the discharge summary and inadvertently attached another resident's health information record to it. The designated representative of Resident #535 informed the Administrator about receiving the incorrect health information, but they could not recall the name of the other resident involved and were unable to provide copies of the returned health information record. Resident #535 had been admitted to the facility with diagnoses of Diabetes, Hypertension, and Muscle Weakness and was discharged to the care of their family.
Plan Of Correction
Plan of Correction: Approved March 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 discharge 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.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report alleged violations of abuse, including injuries of unknown origin, to the state survey agency within the required two-hour timeframe for two residents. Resident #110, who had diagnoses including heart failure, dementia, and atrial fibrillation, was found with a bruise on 10/27/24. The injury was reported to the floor nurse on the same day, but the state agency was not notified until 10/30/24. The Director of Nursing, who was on vacation at the time, acknowledged the delay and stated that an investigation was initiated, but the findings were inconclusive. The Medical Director noted the resident's high risk for bruises due to their medical history but was unaware of the reporting delay. Resident #186, with diagnoses including dementia and a history of breast cancer, was found with a forehead hematoma and cheek injuries on 1/12/25. The resident was unable to explain the cause of the injuries, and the state agency was not informed until 1/16/25. The Director of Nursing confirmed the delay in reporting, and the Administrator acknowledged the requirement to report such injuries within two hours. These incidents indicate a failure to adhere to the facility's policy on timely reporting of suspected abuse or injuries of unknown origin.
Plan Of Correction
Plan of Correction: Approved March 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. 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.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure that residents and their representatives were provided with written notification of transfer or discharge, including sending a copy to the Ombudsman, as required by regulations. This deficiency was identified during a survey conducted from January 22 to January 30, 2025, involving a resident who was transferred to the hospital. The facility did not have a documented policy addressing the notification process for residents, their representatives, and the Ombudsman regarding the reasons for hospital transfers. The specific case involved a resident admitted with diagnoses of Anemia, Coronary Artery Disease, and Hypertension. On December 25, 2024, the resident experienced several episodes of vomiting and diarrhea, prompting a physician to order a hospital transfer. Although the family was notified, there was no documented evidence that the Ombudsman was informed of the transfer. The Director of Social Work acknowledged the oversight, stating that notices were only sent if a resident was admitted to the hospital, not if they were sent to the emergency room and returned without admission.
Plan Of Correction
Plan of Correction: Approved March 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 returned 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 the 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 for 3 months, then quarterly for action as appropriate.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing of the facility's bed hold policy during a hospitalization event. Specifically, a resident with diagnoses including anemia, coronary artery disease, and hypertension was transferred to the hospital following several episodes of vomiting and diarrhea. Despite the transfer, there was no documented evidence that a written notice of the facility's bed hold policy was provided to the resident or their representative. The facility's policy, dated November 9, 2023, required that a copy of the bed hold retention policy be included with the resident's hospitalization documents. However, the Director of Social Work admitted that they did not send the notification of the facility bed hold policy if a resident was sent to the emergency room and returned without being admitted to the hospital. This oversight was identified during a survey conducted from January 22 to January 30, 2025, and the facility was unable to provide the necessary documentation when requested by the surveyor.
Plan Of Correction
Plan of Correction: Approved March 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 provided 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. 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 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 letters are provided at the time of transfer. Social services is responsible for issuing bed hold letters 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 a weekly audit of the transfer log x 1 month, then monthly x three months. If during the audit it is discovered that a resident did not receive the notice, this will remediate by 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.
Failure to Report and Assess Resident Fall
Penalty
Summary
The facility failed to provide timely assessment and treatment for a resident who experienced an unwitnessed fall. The resident, who had diagnoses including Parkinson's Disease, Dementia, and Diabetes Mellitus, was at risk for falls and required moderate assistance for activities of daily living. On the date of the incident, the resident was found on the floor by a Food Service Worker, but the fall was not reported by the Certified Nurse Aide (CNA) and Licensed Practical Nurse (LPN) involved. Consequently, the resident was not assessed or treated immediately after the fall. The facility's policy required staff to notify a licensed nurse if a resident sustained an accident or injury of unknown origin. However, the CNA and LPN involved did not report the fall to the nursing supervisor or conduct an assessment. The resident was only transferred to the hospital the following day after a bruise was noted on their back, where it was discovered that the resident had sustained a fractured scapula and fractured ribs. Interviews with the staff revealed that the CNA and LPN initially denied the occurrence of a fall but later admitted to assisting the resident off the floor without notifying the supervisor. The Director of Nursing confirmed that the resident was moved before an assessment was conducted, leading to a delay in treatment. The medical doctors involved stated that the resident should have been assessed immediately and that earlier notification could have expedited hospital transfer and treatment.
Plan Of Correction
Plan of Correction: Approved March 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 the 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 for one month and monthly for three months by the Director of Nursing or Designee. All results from the audits completed will be reported to the QAPI committee for three months for appropriate action.
Infection Control Deficiencies in Water Management and PPE Use
Penalty
Summary
The facility failed to maintain infection control prevention practices, as evidenced by the absence of a documented environmental risk assessment and water management plan to prevent and control Legionella and other waterborne pathogens. The Director of Facilities and Lead Engineer were unaware of who was responsible for completing these assessments, and no updates had been made from November 2023 to January 2025. This lack of documentation and clarity in responsibility indicates a significant oversight in the facility's infection prevention and control program. Additionally, an environmental service worker entered a contact isolation room without donning personal protective equipment or performing hand hygiene, despite the resident being on contact precautions for Clostridium difficile. The worker admitted to not paying attention to the precautionary signage and acknowledged the need for proper infection control measures. The Director of Nursing and the Infection Preventionist confirmed that all staff are required to follow these protocols, highlighting a lapse in adherence to established infection control guidelines.
Plan Of Correction
Plan of Correction: Approved March 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 on 1/30/25. 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 be conducted by 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 the 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.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to ensure a person-centered comprehensive care plan was developed and implemented for a resident who was reviewed for hospice care. The resident, who was admitted with diagnoses including dysphagia, cerebral aneurysm, and dementia without behaviors, had a significant change in their condition as documented in the Minimum Data Set, indicating severely impaired cognition. Despite the resident being accepted onto hospice care effective January 15, 2025, there was no documented evidence of a care plan being developed. The Registered Nurse Supervisor acknowledged the oversight, attributing it to their absence from the facility and recent return to work.
Plan Of Correction
Plan of Correction: Approved March 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 the 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.
Failure to Implement Fluid Restriction for Resident
Penalty
Summary
The facility failed to ensure that Resident #163, who had diagnoses including Alzheimer Disease, End Stage Renal Disease, and a history of Tachycardia, maintained acceptable parameters of nutrition and hydration status. The resident was on a physician-ordered fluid restriction of 960 milliliters per day due to dialysis needs, but there was no documented evidence of the implementation of this restriction. The resident's meal ticket did not reflect the fluid restriction, and there was no record of daily fluid intake in the electronic medical record. Staff members, including a Registered Dietician, Kitchen Supervisor, Certified Nurse Aide, and Licensed Practical Nurse, were unaware of the fluid restriction or did not ensure it was documented and communicated properly. The facility's policy on managing fluid restrictions was not followed, as evidenced by the lack of intake and output documentation and the absence of fluid restriction information on the resident's meal ticket. Interviews with staff revealed a lack of awareness and communication regarding the resident's fluid restriction, with the Director of Nursing acknowledging that the meal ticket should have documented the restriction and that intake and output should have been recorded separately. The Food Service Director/Dietician also noted that the dietician was responsible for ensuring the fluid restriction was on the meal ticket and that meal rounds should be conducted to ensure compliance, but these actions were not regularly performed.
Plan Of Correction
Plan of Correction: Approved March 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 F692. 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.
Inadequate Documentation and Oversight of Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. Specifically, there was no documented evidence of consistent assessment and oversight before, during, and after dialysis treatment for a resident who received hemodialysis treatments at a community-based dialysis center. The facility's policy required monitoring of residents receiving hemodialysis, including checking for the presence of thrill and bruit at the arteriovenous fistula daily and documenting the resident's condition, including vital signs and post-dialysis weight. However, the documentation was inconsistent, and there were no pre and post-dialysis notes in the progress notes for several dates in January 2025. Interviews with facility staff revealed that the communication book used to document dialysis treatments was not consistently used, and the dialysis center staff did not write in the book. The Assistant Director of Nursing was unaware that the dialysis center should have been writing in the communication book and noted that the facility staff were expected to check the resident pre and post-dialysis and document a progress note. The Director of Nursing stated that the use of the communication book had stopped during COVID-19, and they were not aware it was still not being used. The dialysis center's Registered Nurse Manager reported poor communication with the facility, with calls often going unanswered and documents not being consistently sent to the facility.
Plan Of Correction
Plan of Correction: Approved March 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. 3. 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 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 of 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.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance reviews for nursing staff were completed at least once every 12 months, as required by their policy. Specifically, the facility was unable to provide annual performance reviews for two Certified Nurse Aides. The facility's policy, revised in December 2014, mandates routine and periodic appraisals of job performance and competencies for each employee, with evaluations conducted annually. During interviews, the Director of Human Resources acknowledged that departments were responsible for completing these appraisals and that notifications and reminders were sent via email and during morning reports. However, they could not explain why the appraisals for the two Certified Nurse Aides were not completed. The Administrator noted that there were shortcomings in completing annual performance appraisals during 2023-2024 due to the human resource director position being a corporate shared role rather than a dedicated role for the facility.
Plan Of Correction
Plan of Correction: Approved March 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. 2. 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 required nursing staff receive an annual performance review. All nursing supervisors will receive email notification to remind them that annual performance evaluations are due. The 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 the 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 for one month, then monthly for 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 three months to the QAPI committee for action as appropriate.
Failure to Post Nurse Staffing Information Prominently
Penalty
Summary
The facility failed to ensure that the current resident census and the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift were posted in a prominent place, readily accessible to residents and visitors, on three of the six days reviewed during the recertification survey. From January 22 to January 24, the daily resident census and nurse staffing information were not visible in a prominent location. Interviews with the Director of Nursing and a Nurse Manager revealed that the staffing reports were typically placed on a table near the front desk security, but during an observation, the information was found obscured by other papers, making it not visible to residents or visitors. The Administrator acknowledged the issue and stated that the data would be relocated to a visible bulletin board at the lobby entrance.
Plan Of Correction
Plan of Correction: Approved March 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 in-service 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.
Deficiency in Nurse Aide In-Service Training Hours
Penalty
Summary
The facility failed to ensure that certified nurse aides received the required 12 hours of annual in-service training, as mandated by their corporate policy. Specifically, three out of five reviewed Certified Nurse Aides did not complete the necessary training hours. Certified Nurse Aide #18 completed only 6.0 hours, Certified Nurse Aide #20 completed 6.5 hours, and Certified Nurse Aide #21 completed 9 hours of training. This deficiency was identified during a recertification survey conducted from January 22 to January 30, 2025. The Nurse Educator and the Administrator both acknowledged the shortfall in training hours. The Nurse Educator cited technical difficulties that prevented the completion of in-services at nurse stations, while the Administrator mentioned challenges related to staff time and technical issues. The online in-service program was removed from unit computers due to these technical issues, requiring staff to use facility classroom computers, which was difficult due to their workload and inability to leave their units during shifts.
Plan Of Correction
Plan of Correction: Approved March 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 in-service 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. 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, with one hour allotted for each training, and all attendance will be tracked and trended. The 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.
Delayed Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were submitted within the required 14 days after completion for two residents. Resident #129's Quarterly MDS, with an assessment reference date of November 15, 2024, and a completion date of November 20, 2024, was not submitted until January 24, 2025. Similarly, Resident #225's Quarterly MDS, with an assessment reference date of November 18, 2024, and a completion date of November 27, 2024, was also submitted on January 24, 2025. During an interview, the MDS Coordinator acknowledged that the assessments were completed but not transmitted due to a change in status in the medical record to 'do not transmit' to the Centers for Medicare Services, though the reason for this change was unknown. The Director of Nursing was unaware of the delay and stated that the MDS Coordinator was responsible for submitting the assessments.
Plan Of Correction
Plan of Correction: Approved March 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 completed 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. "Facilities are required to electronically transmit MDS data to the CMS system for each resident in the facility." An audit tool was developed to ensure all submissions 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: "PREVIOUS MDS/ARD/TRANSMISSION STATUS," "EXPORT READY," and "ACCEPTED." 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 designee checks her own assigned unit every week to ensure that MDSs are completed, locked with "EXPORT READY" status, and checks the said column in the MDS schedule. The Director of the Clinical Compliance and/or designee will transmit the "EXPORT READY" status MDSs to CMS. Upon completion of the transmission process in PCC, the RAUM Manager and/or designee checks the "ACCEPTED" column. A meeting with RAUM Managers and in-service regarding the transmission process will be conducted, and this audit will be done bi-weekly for two months, then bi-weekly for 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. The audit will be done by the Director of MDS or designee bi-weekly for one month, then monthly for three 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 three months for action as appropriate.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, who was moderately cognitively impaired and had a history of Alzheimer's disease, alleged that the CNA threw towels at them and yelled for them to say 'please' when they requested assistance while vomiting. The CNA then left the room without completing the care. This incident was not immediately reported to a supervisor by the Licensed Practical Nurse (LPN) who intervened. The facility's investigation revealed that the CNA did not deny the allegations and was unable to provide a clear account of the events. The CNA was allowed to continue working with other residents for the remainder of their shift, despite the allegations. The Director of Nursing concluded that the CNA had committed abuse based on their refusal to deny the incident and their lack of cooperation during the investigation. The facility's policy on abuse prevention and reporting requires all staff to report any incidents or suspicions of abuse to their supervisor. However, in this case, the LPN did not report the incident, and the CNA continued to work until the end of their shift. The facility's failure to immediately address the situation and remove the CNA from duty contributed to the deficiency in protecting the resident from abuse.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report an alleged violation involving abuse to the New York State Department of Health within the required 2-hour timeframe. This deficiency was identified for two residents. In the first case, a Certified Nurse Aide reported to an LPN that a resident had a skin injury on the right side of their head. The LPN did not assess the injury or notify their supervisor, and the incident was not reported to the Department of Health until two days later. The resident, who was severely cognitively impaired, was found with a significant bruise near their eye, but showed no signs of pain and was unable to describe what happened. In the second case, a resident alleged that a Certified Nurse Aide threw a towel at them and yelled during an episode of vomiting. The resident, who was moderately cognitively impaired, reported the incident to a Social Worker, who then informed the Director of Nursing. The LPN who was aware of the incident did not report it immediately, allowing the aide to continue their shift. The incident was reported to the Department of Health the following day. The facility's policy requires immediate removal of staff involved in alleged abuse from duty pending investigation, but this was not followed in either case. The Director of Nursing was not informed of the incidents in a timely manner, and the facility's failure to adhere to reporting protocols resulted in delayed investigations and potential risk to residents.
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A resident with spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, and a tracheostomy was on continuous pulse oximetry with ordered SpO2 parameters and linked Vocera alerts. When the resident’s oxygen saturation dropped significantly, the Vocera system sent sequential alarms to the primary RN, buddy RN, charge RN, and RT. The primary RN repeatedly pressed “Accept” on the alert device without assessing the resident, while the buddy RN, charge RN, and RT did not respond to the alarms, each assuming others would intervene or not recalling the alert. For approximately 25 minutes, no assigned clinician assessed the resident despite ongoing alarms, until another RN, not assigned to the resident, heard an alarm while passing the room and found the resident unresponsive and gray. A Code Blue was initiated, CPR was performed, and the resident was transferred to the hospital, where they were found to have no brain activity and later died. The facility’s investigation determined that staff failed to respond to and appropriately manage the pulse oximetry/Vocera alerts and failed to maintain and use required communication devices as expected.
A resident with Parkinson’s disease, dementia with behavioral disturbances, and known exit-seeking behaviors, care planned with a wander alarm, eloped through a 3rd floor stairwell door whose alarm had been disabled days earlier by maintenance and security while addressing a wandering system issue. A plastic barrier was placed in front of the door, but the door remained accessible and unrepaired. Video showed the resident repeatedly attempting to exit, bypassing the barrier, trying to remove the wander device, and ultimately opening the door, falling into the stairwell, and leaving the unit. Staff observed the resident at the door but did not consistently redirect them, and the resident was later found outside the building by a visitor after staff realized the resident was missing and discovered the wheelchair in the stairwell.
Two residents with psychiatric and behavioral histories were waiting by an elevator in a lobby when one, known to have prior aggressive behavior and a care plan noting risk for physical aggression, removed a wheelchair armrest and struck the other in the forehead, causing a bump and laceration that required ED evaluation. Video, staff, and security accounts confirmed that the aggressor resident was able to access and weaponize the removable armrest in a common area despite prior documented altercations and behavioral concerns, and was only on 30‑minute checks at the time, resulting in a failure to protect another resident from physical abuse.
Staff failed to respond promptly to an oxygen alert alarm for a resident with spastic quadriplegic CP, severe hypoxic ischemic encephalopathy, chronic respiratory failure, severe cognitive impairment, and total dependence for ADLs, resulting in the resident being found unresponsive with gray skin and requiring a Code Blue, CPR, and hospital transfer where no brain activity was found and life support was later withdrawn. Despite facility policy requiring alleged or suspected neglect and serious bodily injury to be reported to the State Agency within 2 hours (or within 24 hours if no serious bodily injury), the Administrator was not notified until days after the event and the NYS DOH was notified four days after the incident; the DON reported they were initially unaware of the failure to respond to alarms or of the need to report the incident, and the Administrator stated they had not been informed of the Code Blue on the day it occurred.
Surveyors found that the facility failed to implement an effective infection surveillance and reporting process during a norovirus gastroenteritis outbreak and in its routine infection tracking. During the outbreak, only a single-day tracking sheet was completed for several residents with gastrointestinal illness on two units, and daily surveillance with updated symptoms and management was not maintained as required by facility policy. Despite receiving a directive from the state health department to submit a Nosocomial Outbreak Reporting Application for the identified cluster, the DON acknowledged that the report was never submitted. Additionally, monthly infection control line lists for residents on antibiotics for various infections lacked documentation of signs and symptoms, diagnostic and lab results, precautions used, and outbreak potential, even though the IP relied on these lists for surveillance.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
The facility did not ensure residents understood how to file grievances and failed to document and track grievances and their resolutions. Residents reported that they only voiced concerns during resident council and were unclear about the grievance process otherwise, and the designated Grievance Officer could not produce a grievance log or forms. The DON acknowledged the grievance process was informal and lacked clear documentation. In addition, a resident with significant cardiac and neurologic conditions and moderately impaired cognition had a representative who raised multiple concerns about care coordination, communication, discharge planning, call bell response, personal property, preferences, and nutrition, but these grievances were largely handled verbally, with no consistent documentation of how each concern was addressed or resolved.
Surveyors found that the facility failed to provide timely toileting assistance and call bell response for multiple residents who were dependent on staff for ADLs. A resident with Parkinson’s disease and dementia, care planned for two-hour toileting checks, was found by family with urine-saturated clothing and wheelchair cushion after a CNA admitted not changing or checking on the resident for most of a shift, and documentation showed numerous missing toileting and check entries over several months. Another resident with a history of stroke and MI, requiring maximal assist for toileting, reported long waits for morning care while the call bell rang, with staff not responding for extended periods, and the resident’s representative described multiple episodes of call bell waits exceeding an hour. Resident Council minutes, call bell audits, and observations showed repeated long call bell wait times, including bells ringing for 15–45 minutes while various staff passed the rooms without responding, and a spouse reported frequent overnight calls from a resident seeking help because call bells were unanswered.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
A resident with vascular dementia, behavioral disturbances, and dependence for transfers and toileting was sent to the hospital for suspected GI bleeding, with documentation indicating an unplanned hospital transfer and anticipated return. An IDT meeting held earlier did not document any discharge planning, and the resident’s care plan lacked a planned discharge. While the resident remained hospitalized, the facility issued a same-day discharge notice citing inability to meet needs and endangerment to others, based on interference from the resident’s guardians rather than documented resident behavior, and later did not accept the resident back after medical clearance. The medical record contained no IDT discharge plan and no subsequent nursing or social work notes, demonstrating a lack of documented discharge planning and coordination.
Failure to Respond to Pulse Oximetry Alarms for Tracheostomy-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring respiratory care and continuous pulse oximetry monitoring received services consistent with professional standards of practice and the resident’s care plan. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, and chronic respiratory failure, was severely cognitively impaired, and was totally dependent on staff for all ADLs. The care plan and physician’s orders required mechanical ventilation with CPAP to tracheostomy collar overnight, humidified trach collar oxygen during the day, and maintenance of oxygen saturation above 92%, with pulse oximeter alarm parameters set to alert below 92%. The resident was equipped with a pulse oximeter linked to the Vocera alert system, which generated alarms at the bedside and on staff mobile devices when oxygen saturation fell outside ordered parameters. On the day of the incident, the resident’s oxygen saturation dropped to 84% at 8:58 AM, triggering an alert to the primary RN via the Patient Safe Solutions/Vocera system, followed by sequential escalation to the buddy RN, the charge RN, and the RT when not acknowledged. The Call Point Detailed Activity Report showed that an alert was sent to the primary RN at 8:58 AM, to the buddy RN at 8:59 AM, and to the charge RN and RT at 9:01 AM. The primary RN pressed “Accepted” on the device at 9:04 AM, and again when the system alerted at 9:17 AM and 9:18 AM, but did not go to the resident’s room to assess the resident and did not document any assessment or intervention. The buddy RN reported not recalling hearing the alert and stated they were administering medications and unaware of the resident’s distress until the rapid response was called. The charge RN acknowledged receiving the alert but did not respond timely, stating they expected the primary or buddy nurse to respond. The RT stated they received the alert but were busy with other residents and expected other staff to respond. From 8:58 AM to 9:23 AM, no assigned nurse or RT responded to the alarms or performed a clinical assessment of the resident, and the alarm cycle continued without intervention. At 9:23 AM, a second alert was triggered when the resident’s oxygen saturation dropped to 52%. An RN who was not assigned to the resident heard an alarm while passing the room, entered, and found the resident in a wheelchair, unresponsive with gray skin. This RN activated a rapid response/Code Blue, assisted in returning the resident to bed, and another RN began chest compressions. EMS was called and arrived at 9:44 AM; a pulse was briefly restored, and the resident was placed on a ventilator and transferred to the hospital, where they were determined to have no brain activity. Life support was later terminated and the resident expired. The facility’s own investigation concluded that nursing and respiratory staff failed to respond to alarms, failed to appropriately acknowledge and review alerts, failed to maintain accessibility to required communication devices, and failed to escalate when they were occupied or unable to respond, resulting in actual harm and Immediate Jeopardy to the resident and placing other monitored residents at risk.
Removal Plan
- Review camera footage, Patient Safe Solution phone verification notifications, and the pulse oximetry policy.
- Re-educate involved staff on pulse oximetry alarm response, notification handling, and escalation expectations.
- Send voice alarm presentation via email to all assistant nurse managers and assistant directors of nursing for review during evening and morning huddles.
- Ensure Vocera device functionality is reviewed and staff are instructed to keep devices accessible and operational.
- Have IT/MIS check and confirm monitoring equipment is functioning properly.
- Implement disciplinary action for staff involved.
- Discuss and initiate a root cause analysis.
- Review and revise the pulse oximetry policy.
- Provide leadership oversight.
- Implement an audit of alert response times.
Elopement of High-Risk Resident Through Disabled Stairwell Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with known exit-seeking behaviors and elopement risk. The resident had diagnoses of Parkinson’s disease, dementia with behavioral disturbances, and anxiety, and was assessed as having moderately impaired cognition. The resident’s MDS documented exit-seeking behaviors and daily use of a wander/elopement alarm, and the comprehensive care plan identified the resident as an elopement risk/wanderer related to disorientation to place, with an intervention for a wandering device on the ankle. A physician’s order also specified a wandering device to the right ankle with checks every shift. The 3rd floor North stairwell door alarm had been disabled by maintenance following a work order dated 07/02/2024. Maintenance and security staff attempted to address a wandering system alarm issue, and the alarm on the 3rd floor North stairwell door was turned off by removing a screw from the alarm box. A yellow plastic accordion-style barrier was placed in front of the door, and nursing staff were notified that the door was broken. However, the door itself remained accessible, and the alarm remained disabled for days prior to the elopement. Staff on the unit, including CNAs, were not all aware that the stairwell door was broken, and the door was not repaired until 07/17/2024. On the day of the incident, video footage showed the resident repeatedly exit-seeking at the 3rd floor North stairwell door over several hours. The resident moved the yellow barrier, wheeled around it, and closed it behind them. At one point, two unidentified staff observed the resident at the door, opened the barrier, and walked away without redirecting the resident. The footage documented multiple attempts by the resident to exit, including attempts to remove the wander alert bracelet and repeated efforts to push on the delayed egress bar with their leg and hands. Eventually, the resident stood from the wheelchair, pushed the crash bar, opened the door, and fell backwards into the stairwell while pulling the wheelchair through. The resident then maneuvered the wheelchair into the stairwell and exited the unit. Staff later discovered the resident missing, found the wheelchair in the stairwell, and the resident was ultimately located outside the building by a visitor and brought back inside by nursing and security. The DON’s investigation summary identified the root cause of the elopement as the 3rd floor North stairwell door alarm being disabled while the door remained broken and unsecured.
Removal Plan
- Resident #1 was placed on 15-minute safety checks and kept under line-of-sight supervision when outside of their room; continued with use of a wander alert device; and resided in a room adjacent to the nursing station for frequent observations.
- All staff were educated on the Elopement policy and what measures to take if a resident went missing, including a power point presentation and post-tests.
- All exit and stairwell doors in the facility on the 2nd and 3rd floors were repaired by an outside vendor.
Failure to Prevent Resident-to-Resident Physical Abuse in Lobby Elevator Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident, despite a known history of aggressive behavior. One resident with paraplegia, mood disorder, major depressive disorder, and anxiety disorder had an established care plan noting potential for physical aggression and risk of being abused. Prior documentation showed that this resident had been involved in a physical altercation with another resident in June of the previous year, during which they reported being punched and stated they hit the other resident back. The care plan was updated at that time to reflect that the resident was abused by peers, with interventions including relocation as needed and a psychiatry referral, but later updates reflecting another resident-to-resident altercation did not include new interventions. On the day of the incident, video surveillance and witness statements documented that the aggressive resident and another resident were waiting at the elevator in the lobby, along with other residents. The second resident, who had diagnoses including schizophrenia and bipolar disorder, approached and stood next to the first resident’s wheelchair. The first resident was seen making hand gestures, then removed the left wheelchair armrest and used both hands to swing it toward the second resident. When the second resident reached toward the armrest, the first resident struck them on the forehead with the armrest, causing bleeding and resulting in a bump and small laceration. Staff arrived immediately after the assault and separated the residents, and the injured resident was later assessed and transferred to the hospital for evaluation. Interviews conducted after the event revealed differing accounts of the interaction leading up to the assault. The first resident reported that the second resident had previously used a racial epithet toward them and, on the day of the incident, again stood close, touched their shoulder, and repeated the racial epithet, prompting them to remove the armrest and strike the other resident. The second resident stated they were standing at the elevator, heard the first resident saying something, ignored it, and were then struck without warning. A security guard reported hearing the first resident tell the second resident not to stand close and to stop touching them, then observed the first resident swinging the armrest and hitting the second resident. Facility staff, including the RN Supervisor and DON, acknowledged that the incident occurred off the unit, that the aggressive resident had a history of verbal and physical abusive behavior toward staff, and that this was the first documented physical altercation between these two specific residents. Despite prior behavioral incidents and care plan documentation of aggression risk, the resident was on 30‑minute checks and was able to access and weaponize a removable wheelchair armrest in a common area, resulting in physical abuse of another resident.
Failure to Timely Respond to Oxygen Alarm and Report Suspected Neglect
Penalty
Summary
Facility staff failed to immediately report an alleged incident of neglect involving a resident who was dependent on respiratory support and continuous monitoring. The resident had spastic quadriplegic cerebral palsy, severe hypoxic ischemic encephalopathy, chronic respiratory failure, was severely cognitively impaired, and totally dependent on staff for all ADLs. On the date of the incident at 8:58 AM, the resident’s alert alarm indicated decreasing oxygen levels, but nursing and respiratory staff did not respond to the alarm or assess the resident in a timely manner, in deviation from the facility’s pulse oximetry escalation pathway and alarm response procedures. The resident was later found unresponsive with gray skin, and a Code Blue was initiated. CPR was started, and the resident was transferred to the hospital, where they were determined to have no brain activity; life support was later terminated and the resident expired. Although the facility’s policy required that alleged or suspected violations involving mistreatment, neglect, or other reportable events be reported to the State Survey Agency and other appropriate authorities no later than 2 hours after forming the suspicion if serious bodily injury occurred, or within 24 hours otherwise, the incident was not reported in accordance with these time frames. The incident occurred on one date, the Administrator was not notified until a later date, and the New York State Department of Health was not notified until four days after the event. The DON stated they were unaware that staff had failed to respond to the alerts until reviewing the alert system report and interviewing staff, and also stated they were unaware the incident should have been reported to the Department of Health, while the Administrator confirmed they had not been notified of the Code Blue on the day it occurred.
Failure to Implement Effective Infection Surveillance and Outbreak Reporting
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program during a norovirus outbreak and in its ongoing surveillance activities. During a norovirus gastroenteritis outbreak, the facility identified multiple residents with gastrointestinal illness on two units, as documented on an infection control tracking sheet for a single date. The facility’s policy on routine infection control surveillance required ongoing assessment of all residents for changes in symptoms or conditions indicative of infection, but surveillance tracking was only completed for one day and was not continued or updated with symptoms or management throughout the outbreak. The DON and the Infection Preventionist (IP) both acknowledged that surveillance tracking sheets should have been completed daily during the outbreak and that they did not know why this was not done. The facility also did not comply with state reporting requirements related to the outbreak. After the cluster of gastrointestinal illness cases was identified, the NYSDOH sent an email to the DON stating that submission of a Nosocomial Outbreak Reporting Application report was required for a single case of a reportable pathogen in a nursing home resident or a cluster of cases above baseline. The DON stated they were aware of this email but confirmed that the requested outbreak report was never submitted to NYSDOH. The DON further stated that NYSDOH should have been contacted immediately when the outbreak was discovered, and that they were not the DON at the time and did not know why the previous DON failed to submit the report. In addition to the outbreak-related issues, the facility’s ongoing infection surveillance line lists for several months were incomplete. The Infection Control Line List for January, February, and March documented residents on antibiotic therapy for various infections, including wound infections, respiratory infections, urinary tract infections, bacteremia, and Clostridium difficile. However, these line lists lacked documentation of infection signs and symptoms, diagnostic tests and laboratory results, the type of precautions used, and any indication of outbreak potential. During interview, the IP confirmed that they used the line list for surveillance and monitoring of residents with infections and on antibiotics, but acknowledged that the lists did not include the required clinical details and precautions. The DON also stated that the IP was responsible for ensuring surveillance included signs and symptoms, diagnostic tests with results, and precautions to prevent outbreaks.
Incomplete and Inaccurate Medication Administration Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records in accordance with accepted professional standards for one resident. For this cognitively intact resident with essential hypertension, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder, and dementia, standing medication orders included multiple daily and twice-daily medications such as antihypertensives, antidepressants, an anticoagulant, a diuretic, an antianginal patch, an inhaler, and other agents. The facility’s medication administration policy required that medications be administered in accordance with physician orders, that documentation of administration be completed on the computer immediately after administration with the nurse’s initials at the corresponding date and time, and that at the end of each shift the medication nurse review the MAR, 24‑hour report, and nurses’ notes to ensure documentation is accurate and complete. Record review of the medication administration audit report for multiple dates in December 2024 showed discrepancies between the scheduled 9:00 a.m. administration times and the times documented as administered for this resident’s medications. On thirteen separate dates, all medications scheduled for 9:00 a.m. were documented as being administered after 12:00 p.m. but before 1:00 p.m. when a particular RN was passing medications to this resident. These documented times did not align with the scheduled administration time and were inconsistent with the policy requirement that medications be given at the right time and documented immediately after administration. The pattern of late documentation occurred on each of the identified dates when that RN was responsible for the medication pass for this resident. In interviews, the RN who administered the medications stated that the resident received most medications at 9:00 a.m. and some at 5:00 p.m., and described issues such as the computer timing out after about 10 minutes, logging the nurse out, and situations where medications might have been given earlier but not clicked off in the system. The RN reported that the documented times (for example, showing around 12:00 p.m.) might not be accurate, could reflect late documentation, and could be affected by computer glitches, but could not recall specific details from the December dates. The Assistant DON reported that one nurse on the unit was responsible for administering medications to approximately 38–40 residents, that the incoming nurse’s start of shift included a narcotic count and report that delayed the start of the medication pass to about 8:30 a.m., and that this left about two minutes per resident to complete the pass by 10:00 a.m. The Administrator stated that their expectation was that nurses review the MAR at the end of the shift and that unit managers run a monthly report, while the Pharmacy Consultant stated they did not review MARs and assumed nursing conducted internal auditing. These practices and conditions contributed to incomplete and inaccurate medication administration documentation for the resident on the identified dates.
Failure to Inform Residents of Grievance Process and Document Grievances and Resolutions
Penalty
Summary
The facility failed to ensure residents were informed about the grievance process and that grievances were documented and tracked in accordance with its grievance policy. The Social Services/Admissions Coordinator, identified as the Grievance Officer, reported that while they interviewed residents and emailed Administration about complaints they could not resolve, they were unable to provide a grievance log or grievance forms. During resident council, multiple residents stated they voiced concerns in the meeting but did not know how to file grievances outside of that setting, and there was no documented evidence listing grievances or the facility’s responses. The DON stated that grievances should be monitored by Social Services with documentation of the nature of the complaint and the resolution, but acknowledged that the process was informal, dependent on circumstances, and not completely clear, with no forms or documentation used to track grievance progress and resolution. For one resident reviewed for care planning, the facility did not consistently address and document multiple grievances raised by the resident’s representative. This resident had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, with the admission MDS indicating moderately impaired cognition and involvement of the resident and family in assessment and goal setting. The representative reported numerous concerns regarding miscommunication between nursing and rehabilitation, discharge planning, appointment scheduling, call bell response time, personal property, resident preferences, nutrition, and proper diet, all of which were communicated to Administration via email and paper copies. Although a family meeting was held to discuss these concerns, the Social Services/Admissions Coordinator and the DON confirmed there was no documented evidence of how each grievance was addressed or resolved, and that most concerns were handled verbally without formal documentation or investigation of every complaint.
Failure to Provide Timely Toileting Assistance and Call Bell Response
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide necessary assistance with toileting and timely response to call bells for residents who were unable to perform activities of daily living independently. Facility policy on Activities of Daily Living required that residents receive appropriate treatment and services to maintain or improve their ability to carry out ADLs, including elimination and toileting, and the facility’s No Pass policy required all staff to respond to call lights and obtain help if they could not provide it themselves. Despite these policies, multiple observations, interviews, and record reviews showed that residents did not consistently receive timely toileting care or call bell responses. One resident with Parkinson’s disease, dementia, heart disease, severely impaired cognition, and total dependence on staff for toileting and hygiene was care planned to be checked for incontinence and changed as needed, and to have toileting needs anticipated every two hours with assistance to the toilet. Kardex instructions for several months reiterated two-hour toileting checks and assistance, and CNA documentation reports for January through March showed numerous missing entries for toileting and two-hour checks across multiple shifts. A nursing home investigative report documented that a family member found this resident with urine-saturated clothing and wheelchair cushion in the afternoon, and the Administrator confirmed the saturation. The CNA identified as responsible for ADLs and accountability tasks for that shift stated they did not change the resident at all during the eight-hour shift, did not perform end-of-day care, and did not inform anyone that they were unable to care for the resident, and also stated they did not check on the resident until late morning. There was conflicting documentation on the assignment sheet, and another CNA reported that the resident was checked every two hours and could indicate when cleaning was needed, while a second family member reported having observed a strong urine smell on three Sunday visits in recent months, which staff addressed when notified. Another resident with a history of stroke and myocardial infarction, and moderately impaired cognition, required maximal assistance with toileting and moderate assistance with bathing and dressing. During one observation, this resident’s call bell was ringing, and the resident reported having waited a long time for care and stated they had been waiting since early morning; staff did not respond until several minutes after the surveyor’s observation began, at which time morning care was provided. On another day, the shared room call bell was ringing while two residents in the room reported they were still in bed, unwashed, undressed, and waiting to get out of bed, stating they had been waiting about half an hour; staff arrived to assist approximately 18 minutes after the surveyor’s initial observation. The resident’s representative reported multiple episodes when call bell response times exceeded one hour and had communicated these concerns to staff. The DON stated that call bells should be responded to when heard and that 30–60 minutes was not acceptable, but also indicated that response time depended on staffing. Additional evidence of delayed call bell response and unmet toileting needs came from Resident Council minutes, call bell audits, and direct observations. Resident Council minutes over several months documented ongoing resident reports that call bell wait times were “on the longer side” and “too long,” and that more nursing staff were needed, particularly on weekends when residents reported only three CNAs were often scheduled. Facility call bell audits conducted in response to complaints documented 23 observations, including one call bell active for 45 minutes and another for 15 minutes in the same room. During one observation, a room call bell rang for at least 14 minutes while multiple staff, including a CNA, a medication nurse, a social work/admissions coordinator, and a unit clerk, passed the room without entering; when the CNA finally entered, the resident requested a bedpan and the CNA left and did not return with the bedpan for another 10 minutes. In another observation, a room call bell rang for at least 27 minutes while a medication nurse, social work/administration staff, and a unit clerk were present in the hallway or nearby but did not respond to the bell. A spouse reported receiving at least 10 overnight phone calls from a resident asking them to call the nurses’ station because no one was responding to the call bell, and also reported that it took a long time for the nurses’ station to answer the phone.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Provide Appropriate Discharge Planning and Readmission for Hospitalized Resident
Penalty
Summary
Surveyors identified that the facility failed to ensure an appropriate discharge plan for one resident who was hospitalized for a suspected gastrointestinal bleed. The resident had vascular dementia with behavioral disturbances, sequelae of cerebral infarction, constipation, and atrial fibrillation, and was dependent for toileting and transfers with documented verbal and physical behaviors toward others. After the resident vomited coffee-ground emesis, the physician ordered a transfer to the hospital emergency department to rule out a GI bleed, and the discharge MDS reflected an unplanned discharge to a short-term general hospital with return anticipated. An interdisciplinary care plan meeting held prior to the hospitalization included multiple disciplines, the resident’s companion, and two guardians, but there was no documentation that discharge planning was discussed, and the resident’s care plan contained no evidence of a planned discharge. While the resident was in the hospital, the facility issued a same-day Transfer/Discharge Notice stating that the IDT had determined the resident would be discharged that day, citing that the resident’s needs could not be met after reasonable accommodation and that the safety and health of individuals in the facility would be endangered. The notice identified interference from the resident’s two guardians as the evidence supporting these reasons, but there was no documentation that the resident personally endangered the health or safety of others. The notice included information about the right to appeal the discharge, and the discharge was appealed. When the resident was medically cleared to return, the facility did not accept the resident back. Review of the electronic medical record showed no documented IDT discharge plan and no nursing progress notes after the date of hospital transfer, and no social work progress notes after that time, indicating a lack of documented planning and coordination related to the discharge decision.
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