The New Jewish Home, Manhattan

Inspectors wroteBased on interview and record review, the facility failed ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of residential property, are reported immediately to the administrator of the facility and to other officials. This was evident for one (Resident #13) of one resident sampled for Abuse. Specifically, on 10/14/2025 at approximately 9:00 PM Certified Nursing Assistants #8 observed discolorations described as large dark brown spot on Resident #13's arm but failed to report it to the supervising nurse. Additionally, on 10/15/2025 at approximately 8:00 AM, Licensed Practical Nurse #4 was made aware of a discoloration described as a dark bluish spot with smaller red spots on Resident #13's right forearm, but failed to report it to the nursing supervisor immediately. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that a person-centered comprehensive care plan was developed and implemented to address the residents' medical, physical, mental, and psychosocial needs. This was evident for one (Resident #3) of six residents reviewed for Abuse. Specifically, the facility did not develop or update the care plan that accurately described care/services to be furnished for a transfer status required Hoyer lift for Resident #3, which created an increase in safety risks as staff rely on active care plans and Kardex to perform the bed-to-wheelchair transfer task.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00332607), the facility failed to protect a resident's right to be free from Abuse. This was evident in 1 of 20 residents reviewed (Resident #1). Specifically, the facility's surveillance camera recording, dated 03/16/2024 at 3:16 AM, showed Resident #1 in their wheelchair being brought into the unlighted dining room by Certified Nursing Assistant #1. Resident #1 was not wearing any clothing or undergarment. While Certified Nursing Assistant #1 was pushing Resident #1's wheelchair, Certified Nursing Assistant #1 used their left hand to hold Resident #1's hands across their chest restricting the movements of Resident #1's hands. [...]

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (NY00332607), the facility did not ensure that a resident was treated with dignity including being free from physical restraint. This was evident in 1 out of 20 residents reviewed (Resident #1). Specifically, the facility's surveillance camera recording, dated 03/16/2024 at 3:16 AM, showed Resident #1 in their wheelchair being brought into the unlighted dining room by Certified Nursing Assistant #1. Resident #1 was not wearing any clothing or undergarment. While Certified Nursing Assistant #1 was pushing Resident #1's wheelchair, Certified Nursing Assistant #1 used their left hand to hold Resident #1's hands across their chest restricting the movements of Resident #1's hands. [...]

Inspectors wroteBased on observation, record review and interviews conducted during an Abbreviated Survey (NY00336486), the facility failed to treat a resident with respect and dignity and care for a resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. This was evident for 1 out of 20 residents reviewed (Resident #11). Specifically, 03/16/2024 at 5:17 PM, the facility's surveillance video recording showed Resident #11 sitting in a lounge chair in the hallway. Resident #11 removed their gown and slid themselves from the lounge chair onto the floor. The Facility's surveillance video recording showed that Resident #1 remained on the floor without clothing (only wearing an adult disposable brief) from 5:24 PM to 5:59 PM (35 minutes). [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 10/31/2024/ to 11/07/2024, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. This was evident during the kitchen and food service observations. Specifically, the walk-in refrigerator and the emergency food storage contained expired food items.

Inspectors wroteBased on interview and record review conducted during the Recertification Survey from 10/31/2024 to 11/07/2024, the facility did not ensure that all alleged violations involving abuse, neglect, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident in 2 (Resident #212 and #188) of 7 residents reviewed for Accidents out of 38 total sampled residents. Specifically, 1.) Resident #212 had an unwitnessed incident on 03/04/2024 when Resident was observed on the floor with bleeding to the left leg. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 10/31/2024 to 11/07/2024, the facility did not ensure that resident environment remains as free of accident hazards as is possible. This was evident in 1 (Sutro 2) of 13 units observed. Specifically, a housekeeping cart containing chemical disinfectants, antiseptic sprays, and bleach was observed unattended in the unit corridor with the cabinet door ajar and the keys hanging from the lock.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey from 10/31/2024 to 11/07/2024, the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice for 1 of 13 units (2nd Floor Sutro Building). Specifically, the facility medication cart was not kept locked or under direct observation of authorized staff.

Inspectors wroteBased on observation, record review, and staff interviews conducted during the Recertification Survey from 10/31/2024 to 11/07/2024, the facility did not ensure that infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, 1.) The facility did not conduct an annual review of the water management plan, and 2.) Enhanced Barrier Precautions were not maintained during intravenous medication administration through a Peripherally Inserted Central Catheter.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 10/31/2024 to 11/07/2024, the facility did not ensure residents, or their designated representatives were provided appropriate notification at the termination of Medicare Part A benefits. This was evident in 2 (Resident #402 and Resident #403) of 3 residents reviewed for Beneficiary Notification out of 38 total sampled residents. Specifically, the facility did not ensure that Notice of Medicare Non-Coverage were mailed to the residents' representatives on the same day telephone notification was made.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 10/16/2023 to 10/26/2023, the facility did not ensure residents' environment received adequate supervision and assistive devices to prevent accidents. This was evidenced for 3 of 3 residents (Resident #162, #243, and #336) reviewed for smoking out of 39 total sampled residents. Specifically, Resident #162 did not have a completed Smoking Safety Evaluation (SSE), was identified as a safe smoker despite a documented incident of smoking in their room on 10/10/2023. Resident #243's Smoking Safety Evaluation (SSE) documented they had incidents of lighting their cigarettes outside of the Designated Smoking Area (DSA). [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification Survey from 10/16/23 thru 10/26/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 2 of 12 Units, (R6 and Sutro3). Specifically, 1) a) Unit R6 - room [ROOM NUMBER]a-was observed with linear broken plaster and paint on room walls. b) room [ROOM NUMBER] with rusty bathroom radiators were missing metal covers, exposing the inner pipes and were layered with dirt and debris. c) Corridor toilet across from room [ROOM NUMBER] had loose ceiling tiles and the call bell was wrapped around the grab bar in the toilet room. e) room [ROOM NUMBER] - loose cable wires. f) room [ROOM NUMBER]b- Crusty thick layered brownish stains on the base of the IV pole. The feeding pump was dusty and with scattered brown stains and streaks. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and extended survey from 10/16/2023 to 10/26/2023, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident for 3 (Residents #25, #252, and #366) of 6 residents reviewed for Activities. [...]

Inspectors wroteBased on observations and interviews conducted during the Recertification survey from 10/16/2023 to 10/26/2023, the facility did not ensure that a safe, functional, sanitary, and comfortable environment was provided for residents, staff, and the public. This was evident during observation of the Library/Activity Room and the facility outdoor Patio/Garden. Specifically: 1). The Garden Area contained tables that were in disrepair, had broken furniture, banister, tiles, blinds, and umbrellas; and 2). The Library Room was observed in disrepair with signs of water damage, black and green colored substance on the wood paneling, peeling plaster, and mis-hung book shelves.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey from 10/16/2023 to 10/26/2023, the facility did not ensure to promote a resident's right to self-determination through support of resident choice. This was evidenced for 1 (Resident #294) of 39 total sampled residents. Specifically, Resident #294 preferred to eat breakfast and brush their teeth after being taken out of bed and was observed in bed after breakfast had already been served.

Inspectors wroteBased on record review and staff interview during the recertification, abbreviated (NY00326962) and extended survey conducted from 10/16/23 through 10/26/23, the facility failed to report all alleged violations involving Abuse, Neglect, including injuries of unknown source, to the New York State Department of Health (NYSDOH), within 2 hours after the allegation was made. This was evident for 1 (Resident #79) of 10 residents reviewed for Abuse out of 38 total sampled residents. Specifically, on 3/20/23 and 3/22/23, Resident #79 reported to the Social Worker and the Physical Therapist that they were handled roughly by staff. The facility reported the incident to NYSDOH on 10/26/23.

Inspectors wroteBased on record review and staff interview during the Recertification, Abbreviated (NY#00322426) and Extended Survey conducted from 10/16/23 to 10/26/23, the facility did not ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 1 resident reviewed for Pre-admission Screening and Record Review (PASRR). This was evident for 1 resident (Resident #738) reviewed out of 40 total sampled residents. Specifically, Resident #738 did not have a Level 1 SCREEN prior to the resident's admission to the facility.

Inspectors wroteBased on observations, interview, and record review conducted during the recertification survey from 10/16/2023 to 10/26/2023, the facility did not ensure necessary behavioral health care and services to attain or maintain a resident's highest practicable physical, mental, and psychosocial well-being. This was evidenced for 1 (Resident #25) of 2 residents reviewed for mood and behavior out of 39 total sampled residents. Specifically, Resident #25 did not have adequate intervention to address their reports of anxiety and depression.

Inspectors wroteBased on observation and staff interviews conducted during the recertification survey from 10/16/2023 to 10/26/2023, the facility did not ensure that all medications and biologicals were safely stored and firmly affixed to the inside of the medication refrigerator to prevent possible diversion. Specifically, one unopened vial of a Schedule IV Controlled Substance (Lorazepam/Ativan) was observed stored in a metal box that was attached to the top shelf of the medication refrigerator. The shelf was easily movable and not firmly affixed to the inside of the refrigerator. This was evident during observations conducted for the Medication Storage Task. (Unit R 6). The finding is: The facility policy and procedure titled, Storage of Pharmaceuticals, effective date, May 1, 1996, rev. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification survey from 10/16/2023 to 10/26/2023, the facility did not ensure food was stored in accordance with professional standards for food service safety. This was evident during dining observation on 2 (Sutro 1 and Sutro 3) of 12 units. Specifically, 1) the pantry refrigerator on Sutro 3 was observed containing undated and unlabeled food, and 2) the pantry refrigerator on Sutro 1 was above 41 degrees Fahrenheit (F) and contained unlabeled and undated food.

Inspectors wroteBased on interviews and record review conducted during a recertification survey and abbreviated survey (NY00322660, NY00322237), the facility failed to ensure that all alleged violations involving abuse were thoroughly investigated. This was evident for 2 of 10 residents reviewed for abuse. Specifically, 1.) On 08/22/2023, Resident #147 alleged that Certified Nursing Assistant #11 (CNA #11) pulled their leg while being turned during care. The facility investigated the allegation and gathered statements from the Licensed Practical Nurse #6 (LPN #6) and CNA #11. The investigation did not include statements from other staff or residents who might have potentially witnessed the incident. 2.) On 08/16/2023, the facility received a report from a member of Resident #336's church that a night shift staff threatened to slap Resident #336. [...]

Inspectors wroteResident #484 Urinary Catheter or UTI 12/21/21 10:45AM OBSERVATION : Resident was observed multiple times during the survey period . On initial tour on 12/14/2021 at 10:00am , resident was observed in bed with 2 1/2 SR up in his room with a Foley catheter with the tube touching the floor . The tube was observed with sediments and urine output from the tube is turbid. The drainage bag with a cover . resident with a private aide 24 hrs / day at 12 hours shift each . On interview , the aide states I am her to be his companion , most of the care is done by the CNA and i assist , like walking him in the BR and assisting him in eating and encouraging him. 12/15/2021 -- 12:30 PM -- resident was observed again in his room , seated in his wheelchair , with foley catheter tubing touching the floor. The HHA companion is a male , on his phone and watching TV . RECORD REVIEW : DOB: [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that residents were free of physical restraints. Specifically, a hand mitten were used on a resident without an assessment, care planning, physician's order, or documentation regarding the medical symptoms being treated. This was evident for 1 of 1 resident reviewed for Physical Restraints (Resident #207). The finding is: The facility's policy and procedure titled Restraints dated 09/2012 last revised on 09/2017 documented the following: The facility strive toward a restraint-free environment to allow the resident to maintain his/her highest practicable level of physical, mental, and psycho-social well-being. In the event a restraint is indicated, the following policy and procedure will be followed with goal of minimizing the use of restraints. [...]

Inspectors wroteBased on record review and interviews conducted during the Re-certification Survey from 12/14/2021 to 12/23/2021, the facility did not ensure, to the extent practicable, that residents were involved in developing the comprehensive care plan and making decisions about their care. Specifically, the facility did not ensure that residents and resident representatives were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meeting. This was evident for 1 of 2 residents reviewed for Participation in Care Planning out of a sample of 40 residents (Resident #392).

Inspectors wroteBased on observation, record review and staff interviews during the Recertification survey, the facility did not ensure services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality. Specifically, (1) a resident with a catheter was not receiving catheter care (Resident #484). (2) The nurse did not check to ensure the correct dosage of medication was administered or store the medication per the manufacturer's specifications (Resident #336). This was evident for 2 of 35 sampled residents (Resident # 336 and 484).

Inspectors wroteBased on observation, record review and interviews conducted during the Re-certification Survey from 12/14/2021 to 12/23/2021, the facility did not provide, based on the comprehensive assessment, interests, and the preferences of each resident, an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not appropriately assess the interests and activity preferences of a non-English speaking resident in order to provide an ongoing program of activities designed to meet their interests. In addition, the resident was not provided with television in their native language per their preferences. This was evident for 1 of 4 residents reviewed for Activities (Resident #392). The finding is: [...]

Inspectors wroteBased on observation, record review and staff interviews during the Recertification survey, the facility did not ensure that a resident with a urinary catheter received appropriate treatment and services to prevent urinary tract infections (UTIs). Specifically, there was no evidence that a resident with a foley catheter and history of a UTI received catheter care. In addition, the catheter tubing was observed on the floor. This was evident for 1 of 3 residents reviewed for Catheter Catheter or UTI (Resident #484). The finding is: The facility policy titled Catheter care, Urinary dated April 2017 states The purpose of this procedure is to prevent catheter- associated urinary tract infection in our residents . Purpose with subtitle of Maintaining Unobstructed urine Flow # 4 The urinary drainage bag (Foley catheter) should not touch the floor and should be covered with a dignity bag . [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This was evident in 1 of 2 residents reviewed for care. Specifically, a resident was not provided appropriate clothing. Resident #381 . The finding is: The facility policy titled, Laundry and Labeling Services, Resident /Patient Personal Clothing dated 10/07/2014 documents, The Laundry Department/Vendor is responsible for maintaining inventories, labeling and delivering resident/patient personal clothing. In coordination with Environmental Services, laundry staff may also assist responding to issues /complaints. The procedure as written on Responsibility: [...]

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification survey, the facility did not ensure its residents are free of any significant medication errors. Specifically, a resident prescribed Acetylcysteine 200 milligram (mg)per (/)milliliter (ml) 20% was given Acetylcysteine 200 mg/ml 10% concentration. This was evident for 1 of 35 sampled residents (Resident #336). The finding is: Resident #336 had diagnoses which include: Respiratory Failure on tracheal with Oxygen by collar, Anoxic brain Damage, and Asthma. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired with cognition. On 12/17/2021 at 11:00 AM, Resident #336 was observed with tracheal tube and oxygen by tracheal collar connected at 3 liter (l) with tube feeding in progress. [...]

Inspectors wroteBased on observation, record review, and staff interview conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and stored under proper temperature controls per manufacturer's recommendations. Specifically, an open multi-dose vial of Acetylcysteine was not dated with date of opening and discard date (96 hours after opening), and the vial was not refrigerated after opening per the manufacturer's recommendations. This was evident for 1 of 11 carts observed on 1 of 8 units reviewed for Medication Storage (Unit 7). The finding is: On 12/17/21 at 12:52 PM the unit 7 medication cart was observed with the Registered Nurse (RN). The cart contained a plastic bag containing two multi-dose vials of Acetylcysteine. [...]