Inspection Reports for
Manhattan Nursing & Rehabilitation Center

The complaint investigation was substantiated by interviews and record reviews showing that the CNA continued to have contact with residents despite credible allegations of abuse, and the facility did not follow proper reporting and protective procedures.

The facility failed to implement its abuse prevention policy by not removing the CNA from resident care after multiple abuse allegations, not conducting timely and complete investigations, and not implementing interventions to protect residents from further potential abuse. Two of four residents reviewed were affected by these deficiencies.

The complaint investigation included three complaint investigations (CI MS #2703037, CI MS #266694, CI MS #2670261). CI MS #2703037 and CI MS #2670261 were investigated for resident abuse; no citations were issued for CI MS #2703037, but a citation was issued related to abuse for CI MS #2670261. CI MS #266691 was investigated for resident rights and quality of care with no citations issued.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to implement abuse prevention policies. Specifically, the facility failed to remove a Certified Nursing Assistant (CNA) from resident care following multiple abuse allegations, did not conduct timely and complete investigations, and failed to protect residents from further potential abuse. Two residents were affected by these deficiencies.

The complaint investigations involved three complaint incidents (CI MS#2605137, Incident #2612501, and CI MS#2618796). The investigation found Immediate Jeopardy related to Resident #9's elopement due to inadequate supervision and substandard quality of care. The wound care complaint for Resident #4 was substantiated with deficiencies cited.

The facility was found noncompliant for failing to provide adequate supervision resulting in the elopement of Resident #9, which posed Immediate Jeopardy and Substandard Quality of Care. Additionally, the facility failed to provide wound care as ordered for Resident #4. Corrective actions were implemented and validated by the State Agency.

The complaint investigation found that Resident #4 did not receive wound care as ordered on 09/14/2025. Resident #9 eloped from the facility on 09/08/2025, was found outside unsupervised for 25 minutes, resulting in immediate jeopardy which was removed after corrective actions including one-on-one supervision and staff training.

The facility failed to provide wound care as ordered for Resident #4, missing treatment on 09/14/2025, and failed to provide adequate supervision and a secure environment to prevent the elopement of Resident #9 on 09/08/2025, which resulted in immediate jeopardy that was later removed after corrective actions.

Two complaint investigations (CI MS #27683 and CI MS #27828) were conducted. CI MS #27828 was substantiated with citations for assessing, monitoring, and resident safety (F689 and F656). CI MS #27683 regarding neglect, resident rights, and quality of care had no citations.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to implement a care plan intervention for one-on-one supervision of a severely cognitively impaired resident, resulting in an unsupervised fall causing an acute transverse fracture of the lower sacrum. The facility also failed to provide adequate supervision to prevent accidents, leading to hospitalization of the resident.

The complaint investigation revealed that Resident #1 was assigned one-on-one supervision due to agitation and behavioral disturbances. However, due to staff delays and miscommunication, Resident #1 was left unattended, leading to a fall and injury. The speech therapist did not notify nursing staff of the resident's agitation before leaving, assuming supervision was in place. CNA #2 was late arriving for the shift, and no other staff remained to supervise the resident at the time of the fall.

The facility failed to implement a care plan intervention for one-on-one supervision of a severely cognitively impaired resident, resulting in an unsupervised fall that caused an acute transverse fracture of the lower sacrum. Staff interviews and record reviews confirmed lapses in supervision and failure to follow the care plan.

Six complaint investigations were conducted covering issues such as resident left wet, water not provided, resident neglect, pressure sores, infection control, injury of unknown origin, resident abuse, resident rights violations, and quality of care/treatment. Specific complaint investigation numbers include CI MS #26846, #26887, #26926, #26955, #26996, and #26998.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to failure to accommodate resident preferences for hydration and shaving, failure to provide diets according to resident preferences, and issues related to resident self-determination and dignity.

Six complaint investigations were conducted covering issues such as resident left wet, water not provided, resident neglect, quality of life, death, pressure sores, infection control, injury of unknown origin, resident abuse, resident rights, and dietary services. Specific complaint investigation numbers include MS #26846, #26887, #26926, #26955, #26996, and #26998.

The facility was found not in compliance with state licensure requirements and minimum standards, with deficiencies related to failure to accommodate resident preferences for hydration and shaving, failure to ensure residents received meals according to their preferences, and violations of residents' rights and food preparation standards.

The facility failed to accommodate resident preferences for shaving and hydration for two residents, and failed to ensure dietary preferences for one resident. Observations, interviews, and record reviews confirmed these deficiencies.

Complaint investigations were conducted related to abuse and resident hospitalizations due to hypernatremia; however, no citations were issued related to these complaints.

The facility was found not in compliance with state licensure requirements, citing deficiencies in urinary incontinence care, rehabilitative services, activity programming, safe food handling, and food preparation. No citations were related to the complaint investigations.

Complaint Investigations MS #25970 related to abuse and MS #25912 related to resident hospitalizations due to hypernatremia were investigated with no citations related to the complaints.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing multiple deficiencies including care plan development and implementation, professional standards for services, activity provision, catheter care, food palatability, assistive device provision, food safety, and environmental safety.

The facility failed to develop and implement comprehensive care plans for multiple residents, did not provide adequate activities for residents on the third floor, allowed CNAs to apply medication cream contrary to policy, failed to provide adaptive eating utensils consistently, had issues with food palatability, failed to maintain sanitary food service practices, and did not ensure catheter tubing was kept off the floor. Additionally, biohazard rooms were found unlocked, posing safety risks.

Complaint investigations were conducted for multiple issues including falls, residents left wet for extended periods, call lights not answered, resident assessment, facility cleanliness, quality of care, and resident abuse. Deficiencies were cited related to these complaints.

The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to call light access, comprehensive care plan implementation, and incontinent care leading to potential urinary tract infection risks for residents.

Complaint investigations were conducted for multiple issues including falls, residents left wet for extended periods, call lights not answered, resident assessment, facility cleanliness, quality of care/treatment, and resident abuse. The facility was cited for deficiencies related to call light access and quality of care for residents left wet.

The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. Deficiencies included failure to ensure residents had call light access for communication, and failure to provide appropriate incontinence care to prevent urinary tract infections for a resident with bladder incontinence.

The facility failed to ensure call lights were within reach for residents, specifically Residents #4 and #5, and failed to implement comprehensive care plans as required. Additionally, the facility did not provide appropriate incontinence care to Resident #4, increasing the risk of urinary tract infection.

Two complaint investigations were conducted: CI MS #23812 related to medication administration with no deficiencies cited, and CI MS #23791 related to incontinent care, staffing, and resident neglect, which resulted in deficiencies.

The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements due to failure to resolve resident grievances related to call lights not being answered timely and Certified Nurse Aides not making timely rounds, as evidenced by multiple months of grievance logs and staff interviews.

Complaint investigation MS# 19524 related to Quality of Care for positioning and leaving residents wet or Resident Rights related to visitation was not substantiated, with no citations related to the complaint.

The facility was found not in compliance with several regulatory requirements including management of personal funds, communication rights, timely resident assessments, PASARR coordination, food safety, and pest control. No citations were related to the complaint investigation.

The visit was complaint-related based on resident complaints about access to funds on weekends and mail delivery delays, as well as concerns about MDS assessment timeliness, PASARR referrals, food safety, and pest control.

The facility was found deficient in multiple areas including failure to provide residents reasonable access to their funds on weekends, delayed mail delivery on weekends, untimely completion and transmission of MDS assessments for three residents, failure to refer a resident for Level II PASARR after diagnosis of Bipolar Disorder, improper labeling and storage of food items, and presence of roaches in the dietary area despite pest control measures.

The complaint investigation involved three complaint numbers (#18778, #18743, #18706). The State Agency did not substantiate allegations related to pressure sores, neglect, resident rights, call bell accessibility, resident falls, care not received by physician orders, grooming and odor issues, oversedation, and failure to notify responsible parties and physicians. The facility failed to timely submit the investigation related to Resident #1's neglect allegation, which was unsubstantiated. The investigation was submitted 9 days after the event was first reported, exceeding the 5-day requirement.

The facility was found not in compliance with Medicare and Medicaid participation requirements and cited for failure to report alleged violations timely. The investigation for one resident's neglect allegation was not submitted to the Office of Licensure and Certification within the required timeframe, resulting in a deficiency. Other allegations were not substantiated.

The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 04/04/2022 to 04/10/2022 as required by regulation, which has the potential to cause more than minimal harm to residents.

Complaint Investigation MS #18381, MS #18439, MS #18576, and MS #18645 were conducted. MS #18381, MS #18439, and MS #18645 were substantiated for insufficient staffing; MS #18657 was unsubstantiated.

The facility failed to maintain the required 2.80 hours of direct nursing care per resident per 24 hours for six out of 35 days reviewed, primarily occurring on weekends. No residents had negative outcomes from this deficiency.

Four complaint investigations (MS #18381, MS #18439, MS #18576, and MS #18645) were conducted. MS #18576 was substantiated related to written notification of transfer. MS #18381, MS #18439, and MS #18645 were not substantiated for various allegations including staffing, supplies, call bells, abuse, infection control, food, medications, and resident care.

The facility was found not in compliance due to failure to notify the Resident Representative in writing of a resident's transfer to the Emergency Department for one of three resident transfers reviewed. Other complaints related to staffing, supplies, infection control, and medication administration were not substantiated.

The complaint investigations included CI MS #18242 related to Resident Safety/Accidents (elopement) which was not substantiated, and CI MS #18244 related to failure to provide Resident Services per Physician Orders/Care Plan which was substantiated.

The facility was found not in compliance with Medicare/Medicaid requirements, with an Immediate Jeopardy (IJ) identified for failure to provide enteral feedings, water flushes, and a comprehensive care plan for Resident #2, resulting in serious harm and hospitalization. The IJ was removed on 11/04/21 after corrective actions were implemented and validated.

The complaint investigation substantiated issues related to quality of care and neglect for Resident #13, including failure to provide adequate incontinent care and ADL assistance, resulting in Moisture Associated Skin Damage (MASD). Other complaints related to neglect, quality of care, admissions/transfer/discharge were not substantiated.

The facility was found not in compliance with infection control requirements and substantiated a complaint related to quality of care and neglect resulting in Moisture Associated Skin Damage (MASD) for Resident #13. The facility failed to provide adequate incontinent care, follow the care plan, and maintain proper hygiene, leading to skin damage and neglect. Infection control practices were also deficient, risking spread of infection.

Six complaint investigations were conducted related to pressure ulcers, hydration with PEG tube, wound care, catheter care, dietary concerns, and personal hygiene and hydration. All complaints were determined to be unsubstantiated.

The facility was found not in compliance with infection control regulations, specifically failing to follow COVID-19 infection prevention guidelines. Deficiencies included a Dietary Aide not wearing a face mask properly, a nurse failing to don a gown before entering a droplet precaution room, and a Certified Nurse Assistant failing to wash hands and prevent contamination of clean linens. The facility implemented immediate training and increased staff surveillance to address these issues.

The facility was found not in compliance with requirements related to comprehensive care plans, catheter care, infection prevention and control, and contact precautions. Deficiencies were identified in catheter care technique, infection control practices during medication administration, and adherence to contact precaution protocols.

The complaint investigation revealed failures in catheter care for Resident #173 and infection control during medication administration for Resident #135. Interviews with CNAs, LPN, DON, and Infection Control Nurse confirmed improper practices that could lead to infections.

The facility failed to follow the comprehensive care plan for catheter care for Resident #173, including improper catheter wiping technique that could lead to infection. Additionally, the facility failed to prevent possible infection spread during medication administration for Resident #135, including improper handling of supplies and failure to follow contact precautions.

The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies cited in comprehensive assessments after significant change, accuracy of assessments, development and implementation of comprehensive care plans, care plan timing and revision, qualified persons providing care, bowel/bladder incontinence and catheter care, nutrition and hydration status maintenance, infection prevention and control, and fire safety.