Manhattan Community Care Center

Inspectors wroteBased on observation, facility policy review, record review and interviews, the facility failed to provide adequate bed linens to maintain a comfortable, homelike environment for one (1) of three (3) floors. Second Floor. Findings Included:Record review of the facility policy titled, Departmental (Environmental Services) - Laundry and Linen Revised January 2014, revealed, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing and storage of linen .On 5/12/26 at 3:30 PM, observation and interview revealed the Resident Representative (RR) for Resident #4 was assisting Resident #4 by changing the linens on her bed and there were no pillowcases available on the second floor. Interview with the RR revealed that she had experienced lack of clean linens available for the care of Resident #4 several times in the past. [...]

Inspectors wroteBased on observations, interviews, record reviews and facility policy review the facility failed to ensure call lights were within reach for one (1) of six (6) residents sampled. Resident #2. Findings Included:Record review of the facility policy titled, CALL LIGHT/CALL PAGER SYSTEMS with Revision Date 9/09/22, revealed, Purpose To provide a means of communication to staff for notification of resident needs and a system of communication among staff in the facility; including emergency notifications. All staff. The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. On 5/11/26 at 12:40 PM, observation revealed the call light for Resident #2 was placed under his bed and came up and over the headboard of his bed, so that the call button was behind the headboard and out of the resident's reach. [...]

Inspectors wroteBased on observations, record review, and interviews the facility failed to implement the comprehensive, person-centered care plan for one (1) of six (6) sampled residents. Resident #1. Findings Included:Record review of the Care Plan Detail report for Resident #1 revealed Problem: I have stage 4 pressure ulcer to sacrum. Approaches.that included cleanse sacrum with normal saline pat dry apply Santyl cover with dry dressing daily. An additional care plan revealed Problem: I have a stage 4 pressure ulcer to left lower leg. Approaches. cleanse left lateral leg with normal saline pat dry apply Santyl cover with calcium alginate secure with dry dressing daily. [...]

Inspectors wroteBased on observation, record review, facility policy review and interviews the facility failed to ensure ordered wound treatments were administered as prescribed by the physician for one (1) of six (6) residents reviewed for existing skin impairments. Resident #1. Findings Included:Record review of the facility policy titled, Wound Care dated 1/09/22 revealed the policy stated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. After completing a thorough evaluation, the interdisciplinary team should develop a relevant care plan that includes measurable goals for prevention and management of PU/PIs with appropriate interventions. Orders should include. Frequency of dressing change. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy to protect residents from potential abuse, ensure proper reporting procedures were followed, and prohibit continued staff contact with residents following credible allegations. Specifically, the facility failed to (1) remove the Certified Nursing Assistant (CNA) from all resident care following multiple potential abuse allegations, (2) conduct a timely and complete investigation into resident and family reports of abuse, and (3) implement interventions to protect residents from further potential abuse. This deficient practice affected two (2) of four (4) residents reviewed for abuse (Residents #1 and #2).

Inspectors wroteBased on observation, interviews, record review and facility policy review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of one (1) of six (6) sampled residents, Resident #9. On 9/08/25 a newly admitted respite resident with diagnoses of restlessness and agitation, dementia and senile degeneration of brain and history of exit seeking behaviors and falls was assisted to exit the facility by staff, was outside unsupervised for twenty-five (25) minutes until a staff member observed the resident lying on the ground next to the iron fence that encircled the facility premises, approximately three hundred seventy-five (375) feet from the facility entrance. [...]

Inspectors wroteBased on interview, record review, and policy review the facility failed to provide needed care and services that would meet the resident's physical needs as evidenced by wound care not provided in one (1) of two (2) sampled residents with wounds. Resident #4.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to implement a care plan intervention regarding one-on-one supervision for a severely cognitive impaired resident which resulted in an unsupervised fall, leading to an acute transverse fracture of the lower sacrum for one (1) of two (2) care plans reviewed for falls. Resident #1 Findings Include: A review of the facility's policy, Resident [NAME] of Rights, revised January 2023, revealed: Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life . A. Facility residents shall have the right to: 1 .7 .d. The right to receive the services and/or items included in the plan of care . [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent accidents and failed to ensure continuous one-on-one supervision resulting in a fall that caused an acute transverse fracture of the lower sacrum, leading to hospitalization for one (1) of two (2) residents reviewed for falls. Resident #1. Findings Include: A review of the facility's policy, Resident [NAME] of Rights, revised January 2023, revealed: Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life . A. Facility residents shall have the right to: 1 .34. A safe environment. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to accommodate resident preferences for two (2) of seven (7) residents reviewed.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure residents received a diet that was according to the resident preferences for one (1) of seven (7) sampled residents.

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to maintain sanitary practices within professional standards for food service safety related to hand hygiene for one (1) of two (2) kitchen observations. Findings Included: A review of the facility's policy, Proper Hand Washing and Glove Use, dated 2016, revealed, Guideline: All employees will use proper hand washing procedures .Procedure .4. Employees will wash hands before and after .touching any part of their uniform, face, or hair . On 07/22/24 at 10:29 AM, an observation of the Registered Dietitian (RD) revealed on two (2) occasions while she stood adjacent to the steam table, she picked up an ink pen from the kitchen floor and placed it back on the steam table. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for residents as evidenced by unlocked biohazard rooms on two (2) of four (4) days of survey. Findings Included: During an observation on 07/22/24 at 12:00 PM, there was an unlocked door marked Biohazard on the second floor of the facility. Inside, a red biohazard can was open with red biohazard bags visible, alongside housekeeping chemical dispensers containing Vindicator (a type of disinfectant) and Super Shine All (a type of floor cleaner). A record review of the Safety Data Sheet (SDS), dated 02/04/21, revealed Vindicator had a health hazard for acute oral toxicity and skin corrosion/irritation. A record review of the Safety Data Sheet, dated 10/22/21, revealed Super Shine had a health hazard for serious eye damage/eye irritation. [...]

Inspectors wroteBased on interviews, record reviews, and facility policy reviews, the facility failed to develop/implement the comprehensive care plan for six (6) of thirty (30) sampled residents. Residents #53, Resident #57, Resident #68, Resident #80, Resident #121, and Resident #122 Findings Included: A review of the facility's policy titled, Care Plan Policy, dated 01/15, revealed POLICY: Each resident would have a plan of care to identify problems, needs, and strengths that will identify how the team will provide care The care plan contained services provided, preferences, abilities, and care level guidelines. Procedure: 1. The Care Plan will be developed within two days. Subsequent meetings would take place yearly and as needed. 2. The team along with the resident and/or family members, will identify services needed, preferences, ability, and care level guidelines. 3. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to follow professional standards by allowing a Certified Nursing Assistant (CNA) to apply a medicated cream for one (1) of three (3) residents observed for incontinent care. Resident #80 Findings Include: A review of the facility's policy titled, Medication Administration General Guidelines, dated 8/16/24, revealed, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedure: 1. Medications are prepared, administered, and recorded only by licensed nursing, medical, or other personnel authorized by state laws and regulations to administer medications. 2. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy, the facility failed to provide activities of interest to meet the needs for three (3) of 30 sampled residents. Residents #57, #121, and #122 Findings Included: Record review of the facility's policy titled, Activities/Recreation Services Program Planning Consideration reviewed 10/09 revealed, Policy: Interdepartmental communications and available resources will be utilized to plan, design, and implement the activities program for enhancement of resident participation. Responsibility: Activity/Recreational Director or designees Procedure: 1. Planned programming will be coordinated with and communicated to all departments. 2. Adequate and appropriate supplies and equipment will be provided for the resident's use on an individual and group basis. 3. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to prevent possible complications related to a resident with an indwelling suprapubic catheter, as evidenced by an observation of the catheter tubing on the floor for one (1) of 1 resident reviewed with a catheter. Resident #117 Findings Included: On 07/22/24 at 11:49 AM, during an observation, Resident #117 was in the dining room in his wheelchair. There was a catheter tubing dragging on the floor as he propelled himself throughout the dining room and hallway. A record review of the Physician Orders for the month of July 2024, revealed an order, dated 4/3/24, for a 16F ( French)10cc (cubic centimeter) suprapubic Foley (type of indwelling catheter) to gravity with a closed urinary drainage bag system . [...]

Inspectors wroteBased on observation, interviews, record reviews, and facility policy reviews, the facility failed to provide a palatable meal for lunch for one (1) of two (2) meal observations. Resident #14 Findings Included: A review of the facility's policy Menu Planning and Requirements, dated 2016, revealed, Guideline: Menus are planned to provide nourishing, palatable, attractive meals that meet the nutritional needs of residents served . On 07/22/24 at 12:39 PM, the State Agency (SA) and the Dietary Manager (DM) sampled a lunch tray consisting of a baked pork chop, cabbage, and macaroni and cheese. The DM noted that the macaroni and cheese was bland and lacked a cheese flavor. The SA team concurred with this assessment. On 07/22/24 at 02:24 PM, during an interview, Resident #14 expressed that the food lacked flavor, specifically noting the macaroni and cheese served at lunch was tasteless. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure adaptive equipment was consistently provided at each meal for one (1) of one (1) resident observed during mealtime requiring adaptive utensils. Resident #53 Findings Include: A review of the facility's policy titled, Adaptive Devices, dated 2016 revealed, Guideline: Adaptive eating devices will be available to all residents who need them to promote independence in dining. Adaptive devices will be available for residents at mealtime according to their individualized plan of care. Procedure: . 4. Resident meal cards will specify the resident's order for adaptive devices. 5. Food and Nutrition Services staff will provide each resident is given the appropriate devices(s) for each meal . [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were provided call light access for communication and resident requests as evidenced by, call lights were out of the reach of residents for two (2) of nine (9) sampled residents. Resident #4 and Resident #5.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure that the comprehensive care plans were implemented for two (2) of nine (9) sampled residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review the facility failed to ensure a resident admitted with incontinence of bladder received appropriate treatment and services in a manner to prevent a possible urinary tract infection for one (1) of nine (9) sample residents.

Inspectors wroteBased on facility grievance logs, in-service records, staff interviews, and facility policy review, the facility failed to resolve grievances in a manner that would prevent them from reoccurring as evidenced by four (4) out of six (6) months of resident grievance logs of documented residents' grievances related to call lights not being answered and Certified Nurse Aides (CNAs) not making timely rounds to respond to resident needs.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to appropriately label opened items in the freezer and walk-in refrigerator and properly store perishable items to maintain food quality and prevent contamination, for one (1) of three (3) dietary observations. This has a potential to affect all residents receiving meals prepared by the facility's dietary department.

Inspectors wroteBased on observations, staff interviews, facility protocol review, and facility document review, the facility failed to keep pests out of the food preparation and service areas. Roaches were observed in the dietary area on one (1) of three (3) dietary observations. This has a potential to affect all residents receiving meals prepared by the facility's dietary department. Findings Include: Review of the facility's Pest Control Protocol (undated) stated, General Description: Maintain an effective pest control program so that the facility is free of pests and rodents. The Facility maintains an effective pest control program . A record review of facility pest control contracts revealed that the facility has pest control contracts with two (2) pest control vendors that according to invoices are providing monthly services. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure that residents have reasonable and ready access to their funds, as funds are not available on weekends. This deficient practice has the potential to affect 95 of 95 residents with funds held by the facility. Findings Include: Review of the facility's Resident [NAME] of Rights, dated 11/17, revealed, Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life, regardless of diagnosis, severity of condition or payment source and to exercise those rights as a citizen of the United States without interference, coercion, including those rights specified herein .22. [...]

Inspectors wroteBased on facility policy review and resident and staff interviews, the facility failed to ensure that residents received their mail promptly, within 24 hours of delivery. This had the potential to affect 131 of 131 residents residing at the facility.

Inspectors wroteBased on interviews, record reviews, and facility document review, the facility failed to complete and transmit the Minimum Data Set (MDS) within the required timeframe for three (3) of 31 sampled residents. Resident #1, Resident #11, and Resident #20. Findings Included: A record review of a facility's document presented to the State Agency (SA) by Registered Nurse (RN) #1/Case Mix Consultant, undated, revealed, (Proper Name of Facility) uses the Resident Assessment Instrument (RAI) Manual to code all assessments. A record review of Center for Medicare and Medicaid Services (CMS)'s Resident Assessment Instrument (RAI) Version 3.0 Manual revealed . 5.2 Timeliness Criteria . For all non-admission OBRA (Omnibus Budget Reconciliation Act) and PPS (Prospective Payment System) assessments, the MDS Completion Date . [...]

Inspectors wroteBased on staff interview, facility documentation, and clinical record review, the facility failed to ensure one (1) out of four (4) residents reviewed for Pre-admission Screening and Resident Review (PASARR) were referred for a Level II PASARR after development of a serious mental disorder. Resident #62. Findings Include: Record review of the Pre-admission Screening (PAS) dated 2/12/21 for Resident #62 revealed the resident did not have a serious mental disorder upon admission. Record review of Resident #62's Face Sheet revealed an admission date of 2/11/21. Record review of services provided to Resident #62 on 2/24/22 by Behavioral Health Services LLC, revealed a new diagnosis of Bipolar Disorder. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to follow Resident #173's comprehensive care plan related to catheter care for one (1) of three (3) care plans reviewed for catheter care.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide catheter care in a manner to prevent possible cross contamination/Urinary Tract Infection (UTI), for one (1) of three (3) residents reviewed with catheters. Resident #173.

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to prevent the possible spread of infection during med pass for one (1) of six (6) residents observed during the medication pass, Resident #135.