Inspection Reports for
ManhattanView Center for Rehabilitation and Healthcare

Complaint #NJ00173881 was investigated and the facility was found to be in substantial compliance with federal requirements but deficient in meeting state staffing ratios. No negative outcomes to residents were identified and all residents had the potential to be affected.

The facility was found to be in substantial compliance with federal requirements but was not in compliance with New Jersey state staffing regulations, failing to meet minimum CNA staffing ratios on 10 of 14 day shifts reviewed.

The facility was found deficient in multiple areas including failure to provide timely written notification of hospital transfers and bed hold policies to residents and representatives, late and incomplete Minimum Data Set (MDS) assessments, inadequate nursing documentation of resident death, inaccurate nurse staffing postings, failure to provide appropriate mental health services for a resident with PTSD, inconsistent narcotic medication reconciliation and expired medication storage, failure to maintain sanitary kitchen and pantry conditions, and failure to ensure residents were offered pneumococcal vaccinations according to current guidelines.

Deficiencies were cited in multiple areas including investigation of alleged violations, notice requirements before transfer/discharge, encoding/transmitting resident assessments, services meeting professional standards, pharmacy services and drug regimen review, food procurement and sanitation, immunizations, staffing, infection control, and life safety code compliance.

The complaint involved an allegation that a nurse threw coffee at Resident #46 and verbally threatened the resident. The facility reported the event to the state agency. The investigation included medical record review, staff interviews, and behavior monitoring but was incomplete. The allegation was deemed unsubstantiated. The resident had no visible injuries. The nurse was immediately removed. The investigation lacked key documentation such as the full name and license details of the alleged nurse and witness statements.

The facility failed to timely and thoroughly investigate the abuse allegation. The investigation lacked key documentation including the full name and license information of the alleged nurse, witness statements, and background checks. The allegation was ultimately concluded as unsubstantiated, but the investigation process was incomplete and deficient.

Complaint #NJ00166740 triggered the survey. The complaint was substantiated as the facility was found not in substantial compliance with pharmacy services and staffing requirements.

The facility was found not in substantial compliance with pharmacy services requirements related to medication administration for one sampled resident, and deficient in meeting minimum staffing ratios for certified nurse aides on multiple day shifts. The facility failed to ensure medication was administered according to professional standards and the facility's policy, and staffing ratios were not met on 28 of 28 day shifts reviewed.

The complaint investigation found that medication was not administered as scheduled on 9/6/23 at 6:00 pm, but was documented as administered on 9/8/23 at 11:30 am by the Unit Manager Licensed Practical Nurse (UMLPN). The UMLPN and Director of Nursing were unable to explain the discrepancy.

The facility staff failed to document medication administration as scheduled for Resident #2, with medication administered at an incorrect time and no documented reason for the delay. Interviews with staff revealed lack of explanation for the discrepancy, and facility policy requires documentation of medication administration immediately after giving medications.

Complaint investigation involved multiple complaint numbers (NJ000155531, NJ000156424, NJ000157798, NJ000157860, NJ000157910, NJ000160018, NJ000162621, NJ000162801, NJ000163246). The facility was found in substantial compliance with federal requirements but not in compliance with state staffing standards.

The facility was found to be not in compliance with New Jersey Administrative Code staffing requirements, specifically failing to meet minimum Certified Nurse Aide (CNA) staffing ratios on numerous day shifts over multiple months. The facility was cited for deficient CNA staffing on 55 of 84 day shifts reviewed, potentially affecting all residents. A plan of correction was submitted and completed by 05/25/2023.

The facility failed to maintain the required minimum direct care staff-to-resident ratios on multiple day shifts, failed to ensure 17 of 136 staff received COVID-19 booster vaccinations as required, and did not have a full-time infection preventionist dedicated solely to infection control duties as mandated by state regulations.

The facility was found deficient in multiple areas including failure to evaluate residents for advance directives, inaccurate transcription of physician orders related to enteral feeding, inadequate fall incident reporting and investigation, failure to maintain respiratory equipment properly, lack of timely physician face-to-face visits and order reviews, improper food labeling and storage, and failure to designate a qualified infection preventionist.

Deficiencies were cited related to failure to evaluate residents for advance directives and POLST, inaccurate transcription of physician's orders, failure to report and investigate a fall incident, improper respiratory care, missing physician visits and signatures, improper food storage and labeling, and lack of qualified infection preventionist.

The facility was found to be in noncompliance with fire safety requirements due to deficiencies in the maintenance of the automatic sprinkler system, specifically paint on sprinkler heads and missing escutcheon plates with improper ceiling cuts in the kitchen area.

The facility was found not in compliance with 42 CFR §483.80 infection control regulations, specifically failing to practice appropriate hand hygiene for 4 of 11 staff observed, contrary to CDC guidelines. Deficiencies included inadequate handwashing duration and failure to perform hand hygiene before and after glove use.

The complaint investigation found the facility failed to maintain complete medical records for residents #1 and #2, with missing documentation such as quarterly fall risk assessments, daily Medicare charting, fall care plans, and weekly skin assessments. The facility acknowledged these deficiencies during interviews.

The facility was found not in substantial compliance due to failure to maintain complete and readily accessible medical records for residents, including missing quarterly assessments, daily charting, fall care plans, and weekly skin assessments.

The facility failed to implement Transmission Based Precautions (TBP) for residents under investigation (PUI) for COVID-19 according to CDC guidelines, specifically failing to place Resident #1 on 14-day TBP after hospital readmission, resulting in exposure to Resident #2. The facility's infection control policies and procedures were not properly followed.

The facility failed to ensure that housekeeping staff donned appropriate PPE and followed proper infection control practices when cleaning a room under contact isolation precautions. Observations and interviews revealed inadequate PPE use, improper cleaning and sanitizing of equipment, and inconsistent staff knowledge of isolation protocols.