Inspection Reports for
ArchCare at Mary Manning Walsh Nursing Home & Rehabilitation Center
1339 York Ave, New York, NY 10021, NY, 10021
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
96% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Dec 1, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with regulations regarding resident care, specifically focusing on notification of changes in condition, timely reporting of suspected abuse or neglect, and accident prevention.
Findings
The facility failed to immediately notify the physician and nursing supervisor of a resident's burn injury, delayed reporting the incident to the administrator and state authorities, and did not provide adequate supervision to prevent the accident. The resident sustained third-degree burns after spilling hot coffee while ambulating with a walker.
Deficiencies (3)
F 0580: The facility did not ensure a resident's physician was notified immediately of changes in condition after the resident sustained a third-degree burn from spilling hot coffee. Notification occurred two days later.
F 0609: The facility failed to timely report suspected abuse, neglect, or mistreatment to the administrator and state authorities within required timeframes following the resident's burn injury.
F 0689: The facility did not ensure the resident received adequate supervision to prevent accidents, resulting in the resident spilling hot coffee and sustaining third-degree burns.
Report Facts
Residents sampled: 4
Resident burn incident date: Oct 18, 2025
Physician assessment date: Oct 20, 2025
Incident report submission date: Oct 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Assessed resident's burn, failed to notify supervisor or physician immediately | |
| Registered Nurse Manager #1 | Received delayed notification of resident's burn and showed blisters | |
| Certified Nursing Assistant #1 | Notified Registered Nurse #1 of resident's burn | |
| Physician #1 | Evaluated resident's third-degree burn two days after incident | |
| Director of Nursing | Informed of incident after administrator notification, reviewed incident | |
| Administrator | Notified on 10/20/2025 and reported incident to state authorities |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Dec 1, 2025
Visit Reason
Multiple minor potential harm citations related to accident hazard supervision, notification of changes, and reporting of alleged violations were issued and corrected.
Findings
Multiple minor potential harm citations related to accident hazard supervision, notification of changes, and reporting of alleged violations were issued and corrected.
Deficiencies (3)
Free Of Accident Hazards/supervision/devices — issues with supervision and accident hazard prevention.
Notify Of Changes (injury/decline/room, Etc.) — failures in timely notification of resident condition changes.
Reporting Of Alleged Violations — deficiencies in reporting alleged violations.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 9, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including activities of daily living and food service accommodations.
Findings
The facility failed to provide necessary services for activities of daily living, specifically showers, to a resident unable to care for themselves. Additionally, the facility failed to ensure that residents received food that accommodated their preferences, as evidenced by missing salad on a resident's meal tray.
Deficiencies (2)
F 0677: The facility failed to provide showers as stated in the care plan for Resident #280 who required maximal assistance and was dependent on staff. Showers were infrequently provided due to lack of appropriate equipment and scheduling issues.
F 0806: The facility failed to ensure Resident #404 received food that accommodated their preferences, specifically missing salad on multiple occasions despite documented dietary requests.
Report Facts
Residents reviewed for Choices: 33
Residents reviewed for Choices: 35
Shower frequency documented: 1
Shower schedule days: 2
Care plan initiation date: Nov 25, 2022
Care plan initiation date: Aug 8, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #3 | Reported Resident #280's shower schedule and reasons for missed showers. | |
| Certified Nursing Assistant #1 | Provided bed baths to Resident #280 on non-shower days. | |
| Certified Nursing Assistant #2 | Reported need for reclining shower chair for Resident #280 and assisted with transfers. | |
| Registered Nurse #1 | Unit Nurse Manager | Interviewed regarding Resident #280's shower refusals and equipment availability. |
| Social Worker #1 | Recalled care plan meeting regarding shower requests for Resident #280. | |
| Chief Clinical Officer | Interviewed about awareness of shower issues and grievances. | |
| Administrator | Interviewed about grievances and equipment needs related to Resident #280. | |
| Registered Nurse #2 | Interviewed about missing salad on Resident #404's meal tray and dietary concerns. | |
| Dietician #1 | Evaluated Resident #404's dietary preferences. | |
| Operations Manager | Responsible for assigning employees for meal service and ensuring meal accuracy. | |
| Director of Food Service | Oversees residents' lunch and food service operations. | |
| Assistant Director of Food Service | Assists in overseeing residents' lunch and food service operations. |
Inspection Report
Annual Inspection
Capacity: 60
Deficiencies: 7
Date: Sep 9, 2025
Visit Reason
Citations included minor potential harm issues in ADL care, resident allergies, and multiple life safety code violations involving corridor doors, electrical equipment, and sprinkler system maintenance.
Findings
Citations included minor potential harm issues in ADL care, resident allergies, and multiple life safety code violations involving corridor doors, electrical equipment, and sprinkler system maintenance.
Deficiencies (7)
ADL Care Provided For Dependent Residents — inadequate assistance with activities of daily living.
Resident Allergies, Preferences, Substitutes — failure to properly manage resident allergies and preferences.
Corridor - Doors — life safety code violations related to corridor doors.
Electrical Equipment - Power Cords And Extens — unsafe electrical equipment and power cords.
Electrical Systems - Other — other electrical system deficiencies.
Physical Environment — life safety code concerns with the physical environment.
Sprinkler System - Maintenance And Testing — inadequate maintenance and testing of sprinkler systems.
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Nov 20, 2023
Visit Reason
A widespread minor potential harm citation was issued for deficiencies in reporting to the National Health Safety Network and was not yet corrected.
Findings
A widespread minor potential harm citation was issued for deficiencies in reporting to the National Health Safety Network and was not yet corrected.
Deficiencies (1)
Reporting - National Health Safety Network — deficiencies in required health safety network reporting.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 16, 2023
Visit Reason
The inspection was conducted as part of a Recertification and Complaint survey to assess compliance with regulatory requirements, including abuse reporting and resident safety.
Findings
The facility failed to report an alleged abuse incident involving Resident #14 to the New York State Department of Health within the required 2-hour timeframe. Additionally, the facility did not ensure adequate supervision to prevent elopement of Resident #375, who left the building unescorted despite being identified as high risk and wearing a wander guard.
Deficiencies (2)
F 0609: The facility did not report an alleged abuse involving Resident #14 to the New York State Department of Health within 2 hours as required by policy.
F 0689: The facility failed to provide adequate supervision to prevent elopement of Resident #375, who left the building unescorted despite being identified as high risk and wearing a wander guard.
Report Facts
Residents sampled: 40
Residents reviewed for accidents: 38
Residents reviewed for accidents related to elopement: 5
Residents affected by abuse reporting deficiency: 1
Residents affected by elopement supervision deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Interviewed regarding abuse reporting delay for Resident #14 |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding Resident #375 supervision on 8/8/23 |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding Resident #375 supervision on 8/8/23 |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding Resident #375 elopement incident |
| Security Guard #1 | Security Guard | Interviewed regarding Resident #375 elopement incident |
| Administrator | Administrator | Interviewed regarding Resident #375 elopement incident and system changes |
Inspection Report
Deficiencies: 0
Date: Nov 16, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Mary Manning Walsh Nursing Home CO Inc, related to a regulatory survey completed on 11/16/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Certification Survey
Capacity: 60
Deficiencies: 5
Date: Nov 16, 2023
Visit Reason
Minor potential harm citations were issued for accident hazard supervision, reporting of alleged violations, and life safety code violations including exit signage and sprinkler system maintenance.
Findings
Minor potential harm citations were issued for accident hazard supervision, reporting of alleged violations, and life safety code violations including exit signage and sprinkler system maintenance.
Deficiencies (5)
Free Of Accident Hazards/supervision/devices — issues with supervision and accident hazard prevention.
Reporting Of Alleged Violations — deficiencies in reporting alleged violations.
Responsibilities Of Providers; Required Notif — failures in provider responsibilities and required notifications.
Exit Signage — life safety code violations related to exit signage.
Sprinkler System - Maintenance And Testing — inadequate maintenance and testing of sprinkler systems.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with professional standards of care, focusing on treatment and care planning for residents, specifically addressing bowel management for Resident #1.
Findings
The facility failed to ensure proper documentation and monitoring of Resident #1's bowel function despite known risk factors and physician orders. Multiple interventions were implemented late, and documentation of bowel movements was missing or incomplete, contributing to inadequate care.
Deficiencies (1)
F 0684: The facility did not provide appropriate treatment and care according to orders and resident preferences for Resident #1. There was no documented evidence of bowel movements from 02/11/2023 to 03/16/2023 despite interventions and physician orders.
Report Facts
Residents reviewed: 3
Residents affected: 1
Medication doses: 17.2
Medication doses: 7200
Medication doses: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RNS #1 | Registered Nurse | Documented vomiting and notified Medical Doctor on 03/15/2023 |
| LPN #1 | Licensed Practical Nurse | Documented multiple episodes of vomiting on 03/16/2023 |
| RN #2 | Registered Nurse | Documented family member report of agitation and green emesis on 03/18/2023 |
| Director of Nursing | Director of Nursing | Provided interview about bowel movement documentation process on 04/17/2023 |
| Medical Doctor | Medical Doctor | Ordered tests and treatments, and communicated with family regarding Resident #1 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
A minor potential harm citation was issued for quality of care and was corrected.
Findings
A minor potential harm citation was issued for quality of care and was corrected.
Deficiencies (1)
Quality Of Care — deficiencies impacting quality of care.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jan 13, 2022
Visit Reason
The inspection was conducted as a Recertification survey and complaint investigation to assess compliance with regulatory requirements and quality of care standards.
Complaint Details
The inspection included a complaint investigation (NY00272048) related to care planning and quality of care issues for residents #326 and #574.
Findings
The facility failed to notify a resident's physician of a critical blood sugar reading, did not develop comprehensive care plans for residents after falls or for oxygen therapy, administered oxygen therapy without a physician's order for a period, and failed to label medications properly. Additionally, food handling practices did not comply with hand hygiene standards.
Deficiencies (5)
F 0580: The facility failed to notify the resident's physician when blood sugar reached 350, contrary to physician orders requiring notification for levels above 300.
F 0656: The facility did not develop or implement comprehensive care plans with measurable goals and interventions for resident falls and oxygen therapy.
F 0684: A resident received oxygen therapy without a physician's order for one month, and no care plan was in place for oxygen therapy during that time.
F 0761: Medications including eye drops, insulin vials, and pens were not labeled directly with medication name, dose, expiration date, or instructions; labels were only on plastic bags.
F 0812: Staff failed to perform hand hygiene between tasks during food handling, violating infection control policies.
Report Facts
Residents reviewed for Unnecessary Medications: 35
Residents sampled for care planning: 38
Residents reviewed for Quality of Care: 38
Blood sugar reading: 350
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #2) | Stated reason for not calling doctor about high blood sugar. | |
| Registered Nurse (RN #4) | Stated physician must be contacted for blood sugar over 300 or under 70. | |
| Medical Director | Stated nurses must contact doctor for blood sugar over 300 and explained EMR order discontinuation. | |
| Director of Nursing (DNS) | Stated nurses must call doctor for blood sugar over 300 and follow physician orders. | |
| Registered Nurse (RN #5) | Stated care plan for actual falls must be created immediately after fall. | |
| Registered Nurse (RN #3) | Interviewed about oxygen therapy orders and care plans for Resident #574. | |
| Assistant Director of Nursing (ADN) | Interviewed about oxygen therapy orders and care plans, obtained verbal order on 1/10/22. | |
| Chief Nursing Officer (CNO) | Interviewed about oxygen therapy care plan requirements and EMR system issues. | |
| Registered Nurse (RN #6) | Interviewed about medication labeling practices. | |
| Registered Nurse Supervisor (RN #4) | Interviewed about medication labeling requirements and audits. | |
| Director of Nursing (DON) | Interviewed about medication labeling and expiration date checking. | |
| Second [NAME] | Observed and interviewed regarding failure to perform hand hygiene during food handling. | |
| Food Service Director (FSD) | Interviewed about hand hygiene training for kitchen staff. |
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