Inspection Report Summary
The most recent inspection on December 2, 2025, identified deficiencies related to failure to notify a resident’s representative of a significant change in condition and failure to provide written baseline care plan summaries. Earlier inspections showed a pattern of deficiencies involving resident care communication, abuse prevention, timely treatment, and environmental cleanliness. Inspectors cited issues such as delayed notification of condition changes, failure to protect residents from abuse, and lapses in infection control and food service safety. Complaint investigations included substantiated abuse and reporting failures as well as unsubstantiated abuse allegations, with disciplinary actions taken in some cases. The facility’s inspection history shows ongoing challenges with resident care and communication, with some corrections made but persistent areas needing improvement.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
8.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 2, 2025
Visit Reason
The inspection was conducted as a Recertification and Complaint Survey (Intake 622067) to investigate complaints regarding failure to notify a resident's representative of a significant change in condition and failure to provide a written summary of the baseline care plan to residents or their representatives.
Complaint Details
The complaint investigation found that the facility did not notify Resident #43's family of the resident's hospital transfer and did not provide written baseline care plan summaries to Residents #5 and #98 or their representatives. The family of Resident #43 was upset due to lack of notification about hospitalization.
Findings
The facility failed to notify the representative of Resident #43 about a significant change in condition resulting in hospital transfer, and failed to provide written summaries of baseline care plans to Residents #5 and #98 or their representatives. These failures were confirmed through record reviews and interviews with staff and residents' representatives.
Deficiencies (2)
Failure to notify a resident's representative of a significant change in the resident's status resulting in hospital transfer for Resident #43.
Failure to provide a written summary of the baseline care plan to Residents #5 and #98 or their representatives within 48 hours of admission.
Report Facts
Residents sampled: 40
Residents affected: 1
Residents affected: 2
Baseline care plan completion timeframe: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Nursing Supervisor | Interviewed regarding Resident #43's change in condition and family notification |
| Assistant Director of Nursing | Interviewed regarding notification policies and Resident #43's hospital transfer | |
| Director of Nursing | Interviewed regarding family notification requirements and baseline care plan procedures | |
| Social Worker #2 | Interviewed regarding baseline care plan procedures and communication | |
| Minimum Data Set Assessor | Interviewed regarding baseline care plan completion and distribution | |
| Minimum Data Set Coordinator | Interviewed regarding responsibility for issuing baseline care plan summaries |
Inspection Report
Abbreviated Survey
Deficiencies: 5
Date: Oct 16, 2025
Visit Reason
The inspection was conducted as an abbreviated survey to assess compliance with regulatory requirements related to resident abuse prevention, care planning, treatment and care, pain management, and staff competencies.
Complaint Details
The visit was complaint-related due to an allegation by Resident #7 that Certified Nursing Assistant #9 hit them with a bottle. The allegation was investigated with multiple interviews and assessments. The facility concluded there was no evidence of abuse, neglect, or mistreatment, although the resident had slight swelling and bruising consistent with the allegation.
Findings
The facility was found deficient in ensuring residents were free from abuse, developing and revising care plans timely, providing appropriate treatment and pain management, and ensuring nursing staff had necessary competencies. Two residents suffered fractures with delayed or inadequate response to pain and injury. One resident alleged abuse by a staff member, which was investigated but not substantiated.
Deficiencies (5)
Failure to protect residents from abuse; one resident alleged being hit with a bottle by a staff member.
Failure to develop and revise the complete care plan within 7 days of comprehensive assessment for one resident.
Failure to provide appropriate treatment and care according to orders and resident preferences, resulting in actual harm for two residents with fractures.
Failure to provide safe, appropriate pain management for residents requiring such services, resulting in actual harm.
Failure to ensure nurses and nurse aides have appropriate competencies to care for residents, resulting in delayed treatment and harm.
Report Facts
Residents sampled: 7
Residents affected: 4
Tylenol dosage: 1000
Monitoring frequency: 15
Monitoring duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #4 | Registered Nurse | Named in findings related to failure to enter physician orders and delayed treatment for Resident #4 |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Alleged perpetrator in resident abuse allegation |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Reported Resident #4's pain to nursing staff |
| Physician #1 | Physician | Ordered x-ray and pain medication for Resident #4 |
| Physician #2 | Physician | Evaluated Resident #4 and ordered hospital transfer |
| Physician #3 | Physician | Ordered x-ray and hospital transfer for Resident #5 |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Involved in assessment and transfer of Resident #4 |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Informed about physician orders for Resident #4 |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Apr 30, 2024
Visit Reason
The abbreviated survey was conducted to investigate allegations of physical abuse by nursing home staff against a resident and to assess the facility's compliance with abuse reporting requirements.
Complaint Details
The visit was complaint-related, triggered by an allegation that on 04/19/2024, Certified Nursing Assistant #1 slapped Resident #1 multiple times during incontinence care. The allegation was substantiated by witness statements, physical assessment, and facility investigation. The resident had severely impaired cognition and was unable to report the incident. The facility suspended and terminated the involved staff member.
Findings
The facility failed to protect a resident from physical abuse by a Certified Nursing Assistant who slapped the resident multiple times, resulting in actual harm. Additionally, the facility did not report the abuse allegation to law enforcement and the state health department within the required two-hour timeframe. The facility concluded that abuse occurred and took disciplinary action against the staff involved.
Deficiencies (2)
Failed to protect a resident from physical abuse by nursing home staff, resulting in actual harm.
Failed to timely report suspected abuse to local law enforcement, facility administrator, and the New York State Department of Health within two hours.
Report Facts
Date of incident: Apr 19, 2024
Date of physical assessment with bruise: Apr 20, 2024
Bruise size in centimeters: 2
Bruise size in centimeters: 1.5
Brief Interview of Mental Status score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Staff member who slapped Resident #1 and was suspended and terminated | |
| Certified Nursing Assistant #2 | Witnessed the abuse and reported it to Licensed Practical Nurse #1 | |
| Registered Nurse #1 | Performed initial physical assessment of Resident #1 | |
| Director of Nursing | Conducted physical assessment and notified facility administrator of the incident | |
| Licensed Practical Nurse #1 | Received abuse report from Certified Nursing Assistant #2 and reported to Registered Nurse Supervisor #1 | |
| Registered Nurse Supervisor #1 | Assessed Resident #1 and received abuse report | |
| Administrator | Received notification of abuse incident from Director of Nursing | |
| Medical Doctor | Provided medical opinion on bruise possibly related to trauma or blood thinner medication |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Apr 30, 2024
Visit Reason
Two Level 3 standard health citations for free from abuse and neglect and reporting of alleged violations, both corrected by June 19, 2024.
Findings
Two Level 3 standard health citations for free from abuse and neglect and reporting of alleged violations, both corrected by June 19, 2024.
Deficiencies (2)
R9-10-803.J — Abuse reporting documentation
Reporting of alleged violations
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 1, 2023
Visit Reason
The inspection was conducted as a recertification and complaint survey from 11/27/2023 to 12/01/2023 to investigate a complaint regarding the facility's failure to ensure timely treatment and care for a resident with a change in condition requiring hospitalization.
Complaint Details
The complaint investigation (NY00323859) found that Resident #241's change in condition was not timely communicated to the RN Supervisor by LPN #2, despite observations by the Occupational Therapist and the resident's designated representative. LPN #2 was warned and suspended for failure to report the condition change. The Registered Nurse and Director of Nursing confirmed delayed notification and response.
Findings
The facility failed to ensure that Resident #241 received appropriate treatment and care in accordance with professional standards, as the Registered Nurse and Medical Doctor were not made aware in a timely manner of the resident's change in condition that required hospitalization. Licensed Practical Nurse #2 did not report the resident's condition change to the RN Supervisor, resulting in delayed assessment and transfer to the hospital.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders and resident's condition change, resulting in delayed notification to medical staff and hospitalization.
Report Facts
Residents sampled: 37
Residents affected: 1
Blood Pressure reading: 160
Blood Pressure reading: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Failed to report Resident #241's change in condition to RN Supervisor, resulting in disciplinary action |
| RN #2 | Registered Nurse | Assessed Resident #241 and transferred to hospital after being informed of condition change |
| OT #1 | Occupational Therapist | Observed Resident #241's condition change and reported to LPN #2 and Director of Rehab |
| DON | Director of Nursing | Interviewed regarding the incident and disciplinary action against LPN #2 |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 1, 2023
Visit Reason
The inspection was conducted as a recertification survey from 11/27/2023 to 12/01/2023 to assess compliance with regulatory standards and investigate a complaint (NY00323859).
Complaint Details
Complaint investigation (NY00323859) related to failure to provide appropriate treatment and care for Resident #241, specifically delayed notification of change in condition and hospitalization.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, providing appropriate treatment and care according to professional standards, proper medication storage, food service safety, and infection prevention and control practices. Specific issues included damaged environmental conditions, delayed notification of resident condition changes, expired IV fluids, dirty ice machines and kitchen vents, and failure to perform hand hygiene during wound care.
Deficiencies (5)
Facility did not maintain a clean, comfortable, and homelike environment; issues included missing AC/H unit covers, cabinets in disrepair, cracked bedside table and tile on multiple floors.
Resident #241 did not receive timely notification to the Registered Nurse and Medical Doctor regarding a significant change in condition requiring hospitalization.
Expired intravenous fluid bag found in the 5th Floor medication room.
Food service areas including ice machines and kitchen vents were dirty and dusty across multiple floors and the kitchen.
Registered Nurse failed to perform hand hygiene before and during wound care on Resident #216.
Report Facts
Resident sample size: 37
Resident affected: 1
Resident affected: 1
Floors with environmental deficiencies: 6
Floors with food service deficiencies: 6
Expiration date: 2023.05
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in delayed notification and infection control deficiencies |
| LPN #2 | Licensed Practical Nurse | Named in delayed notification of Resident #241's condition and disciplinary action |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding Resident #241 incident and disciplinary actions |
| Director of Maintenance and Housekeeping (DOM/HK) | Director of Maintenance and Housekeeping | Interviewed regarding environmental and cleaning rounds |
| Maintenance Worker #1 | Maintenance Worker | Interviewed about AC/H unit cleaning schedule |
| Maintenance Worker #2 | Maintenance Worker | Interviewed about ice machine cleaning |
| Pharmacy Consultant (PC) | Pharmacy Consultant | Interviewed about medication room inspections |
| Dietary Aide (DA) #1 | Dietary Aide | Interviewed about kitchen cleaning practices |
| Food Service Supervisor (FSS) | Food Service Supervisor | Interviewed about kitchen cleaning responsibilities |
| Food Service Director (FSD) | Food Service Director | Interviewed about kitchen cleaning schedules and checklists |
| RN #2 | Registered Nurse | Observed failing to perform hand hygiene during wound care on Resident #216 |
| Director of Nursing/Infection Preventionist (IP) | Director of Nursing/Infection Preventionist | Interviewed about infection control rounds |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: Dec 1, 2023
Visit Reason
Multiple Level 2 standard health citations including food sanitation, infection control, medication labeling, quality of care, and environment; and Level 1 and 2 life safety code citations related to building construction, cooking facilities, electrical systems, fire alarm, interior finishes, and sprinkler systems, all corrected by January 26, 2024 except fire alarm corrected December 8, 2023.
Findings
Multiple Level 2 standard health citations including food sanitation, infection control, medication labeling, quality of care, and environment; and Level 1 and 2 life safety code citations related to building construction, cooking facilities, electrical systems, fire alarm, interior finishes, and sprinkler systems, all corrected by January 26, 2024 except fire alarm corrected December 8, 2023.
Deficiencies (15)
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Label/store drugs and biologicals
Quality of care
Safe/clean/comfortable/homelike environment
Building construction type and height
Cooking facilities
Electrical equipment - other
Electrical systems - essential electric syste
Fire alarm system - out of service
Interior wall and ceiling finish
Sprinkler system - installation
Sprinkler system - maintenance and testing
Sprinkler system - out of service
Vertical openings - enclosure
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 20, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to investigate the facility's failure to timely report alleged resident-to-resident abuse to the New York State Department of Health (NYSDOH).
Complaint Details
The visit was complaint-related due to an allegation of resident-to-resident physical abuse involving Resident #6 and Resident #7. The allegation was investigated and found unsubstantiated. The facility reported the incident to NYSDOH more than 2 hours after it occurred, violating reporting requirements.
Findings
The facility failed to report an alleged resident-to-resident physical abuse incident within the required 2-hour timeframe, reporting it approximately 12 hours late. The investigation concluded there was no reasonable cause to believe abuse occurred, but the reporting delay was confirmed by interviews with facility leadership.
Deficiencies (1)
Failure to timely report alleged resident-to-resident abuse to NYSDOH within 2 hours as required.
Report Facts
Residents reviewed for abuse: 13
Residents affected: 2
Time delay in reporting: 12
Laceration size: 1
Laceration size: 1.5
Laceration size: 0.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed acknowledging delayed reporting of abuse incident |
| Director of Nursing | Director of Nursing (DON) | Interviewed confirming abuse allegations must be reported within 2 hours |
| Administrator | Administrator | Interviewed confirming responsibility for timely reporting of abuse allegations |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 20, 2023
Visit Reason
One Level 2 standard health citation for reporting of alleged violations, corrected by January 13, 2024.
Findings
One Level 2 standard health citation for reporting of alleged violations, corrected by January 13, 2024.
Deficiencies (1)
Reporting of alleged violations
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Apr 7, 2022
Visit Reason
Two Level 2 standard health citations for dialysis and reporting of alleged violations, both corrected by May 6, 2022.
Findings
Two Level 2 standard health citations for dialysis and reporting of alleged violations, both corrected by May 6, 2022.
Deficiencies (2)
Dialysis
Reporting of alleged violations
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Oct 5, 2021
Visit Reason
The survey was a recertification survey to assess compliance with regulatory requirements for Northern Manhattan Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including environmental cleanliness and resident room safety due to clutter and stained privacy curtains, inaccurate resident assessments, incomplete and unimplemented care plans especially for residents with hoarding behaviors and pressure ulcers, delayed treatment of urinary tract infection, failure to accommodate resident food allergies and preferences, expired medication supplies in medication rooms, and inadequate infection control practices including oxygen tubing on the floor and lack of a functional water management plan for Legionella.
Deficiencies (9)
Resident room observed with multiple boxes, plastic containers, and tied plastic bags cluttering the space, and stained privacy curtains not changed as scheduled.
Resident #102's Minimum Data Set (MDS) inaccurately documented dialysis treatment which was not provided.
Care plans lacked measurable goals and interventions for a resident with hoarding behaviors and for a resident with pressure ulcer/injury.
Residents #187 and #296 were not invited to quarterly comprehensive care plan meetings as required.
Resident #203 had abnormal urinalysis and urine culture results on 08/28/21 that were not reviewed and treated until 09/21/21.
Resident #100 with hoarding behaviors did not have appropriate behavioral health care and services or interventions to maintain a safe environment.
Expired syringes including insulin and supplements were found in medication carts on Unit 4.
Residents #508 and #509 had oxygen tubing observed touching the floor; facility lacked a functional water management plan, sampling plan, and up-to-date environmental risk assessment for Legionella.
Residents #260 and #267 were served food containing raw onion, raw tomato, and raw cucumber despite documented allergies and preferences to avoid these items.
Report Facts
Residents reviewed for Resident Assessment: 40
Residents reviewed for Behavior/Emotional: 1
Residents reviewed for UTI: 1
Units reviewed for Medication Storage: 8
Residents reviewed for Respiratory care: 3
Residents sampled for dining observations: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Spoke about Resident #100's hoarding behavior and care plan creation |
| LPN #1 | Licensed Practical Nurse | Discussed attempts to encourage Resident #100 to clean room |
| CNA #2 | Certified Nursing Assistant | Reported Resident #100's refusal of help and clutter concerns |
| DON | Director of Nursing | Discussed oversight of Resident #100's hoarding behavior and infection control |
| DSW | Director of Social Work | Discussed care planning meetings and Resident #100's behavior |
| RN #4 | Registered Nurse Supervisor | Checked medication room and found expired syringes |
| LPN #6 | Licensed Practical Nurse | Discussed medication room checks and expired items |
| MD | Physician | Discussed delayed treatment of Resident #203's UTI |
| Lab representative Staff #11 | Laboratory Staff | Explained lab notification procedures for abnormal results |
| RT Staff #3 | Respiratory Therapist | Discussed oxygen tubing care for Resident #508 |
| Food Service Supervisor/Manager | Food Service Supervisor | Discussed food preferences and tray ticket procedures |
| Dietetic Technician | Dietetic Technician | Discussed tray ticket preparation and allergy checks |
| LPN #2 | Licensed Practical Nurse | Discussed monitoring oxygen tubing for Resident #509 |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 12, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with federal regulations regarding resident rights, care, medication administration, and medication storage.
Findings
The facility was found deficient in respecting resident privacy during physician examinations, ensuring appropriate use of adaptive devices for mobility, maintaining medication error rates below 5%, and proper storage and labeling of biologicals. Specific issues included a resident examined in public, failure to apply prescribed hand splints, medication errors including missed doses and incorrect injection routes, and expired biologicals stored beyond manufacturer recommendations.
Deficiencies (4)
Resident privacy was not respected; a physician examined a resident in the dining room in full view of others.
A resident with limited mobility was observed without prescribed bilateral hand splints on two occasions.
Medication error rate exceeded 5%; missed administration of Plavix and incorrect route of Heparin injection.
A multidose vial of Tuberculin Purified Protein Derivative (PPD) was stored and used 21 days past the discard date.
Report Facts
Medication error rate: 7.69
Days PPD vial used past discard date: 21
Residents investigated for dignity care: 2
Residents reviewed for positioning and mobility: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Did not administer Plavix medication as ordered due to lack of stock. |
| LPN #4 | Licensed Practical Nurse | Administered Heparin injection via incorrect route to Resident #309. |
| CNA #1 | Certified Nursing Assistant | Assigned to Resident #180; did not apply hand splints due to resident visitor presence. |
| RN #1 | Registered Nurse | Made referral for splint device and checked residents with splints daily. |
| Director of Rehab | Director of Rehabilitation | Evaluated resident and recommended bilateral hand splints; does quarterly visual rounds. |
| RN Unit Manager #3 | Registered Nurse Unit Manager | Did not communicate missed Plavix dose to evening shift; responsible for follow-up. |
| Nurse Practitioner | Nurse Practitioner | Emphasized importance of notification for missed medication doses. |
| Director of Nursing | Director of Nursing | Provided education on medication re-ordering and medication administration competency. |
| LPN #1 | Licensed Practical Nurse Medication Nurse | Interviewed regarding expired PPD vial found in medication refrigerator. |
| RN #1 Supervisor | Registered Nurse Supervisor | Interviewed about PPD vial expiration and refrigerator checks. |
| Pharmacy Consultant | Pharmacy Consultant | Responsible for medication cart and refrigerator checks; did not identify expired PPD vial. |
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