Manhattanville Health Care Center

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to ensure that a resident who is administered enteral tube feedings, received the appropriate treatment and services to prevent complications. This was evident in 1 (Resident #151) of 2 residents reviewed for Tube Feeding and 1 of 8 residents reviewed during the Medication Administration Task. Specifically, during observation on 06/09/2025 at 9:50 AM, Resident #151's enteral tube feeding formula that was being administered was not labeled with the resident's name, the date and start time of the administration, or the flow rate. Additionally, during medication administration observation conducted on 06/10/2025, Licensed Practical Nurse #1 did not verify the functioning of Resident #151's gastrostomy tube before administering medications.

Inspectors wroteBased on observation, record review, and interview during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to ensure that residents are free of any significant medication errors. This was evident in 1 (Resident #151) of of 8 residents reviewed during the Medication Administration Task. Specifically, Resident #151 was not administered 5 milliliters of Ferrous Sulfate 300 milligram/5 milliliters as ordered by the Physician.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 06/05/2025 to 06/11/2025, the facility failed to store all drugs and biologicals in locked compartments and under proper temperature controls. This was evident in 1 (Unit 3) of 5 medication storage areas observed. Specifically, 1.) Calcitonin spray was kept in the medication cabinet and was not refrigerated, 2.) The medication refrigerator was not locked, and 3.) An opened vial of haloperidol had no date of when it was first opened.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to ensure food were stored in accordance with professional standards for food service safety. This was evident in 1 (Unit 3) of 3 units observed. Specifically, expired frozen food were stored in Unit 3 pantry refrigerator.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. This was evident in 1 (Resident #152) of 1 resident reviewed for Transmission-Based Precautions out of a total sample of 38 residents. Resident #152, who was diagnosed with Clostridium Difficile, was not cohorted and was sharing a room with another resident who was not infected with Clostridium Difficile.

Inspectors wroteBased on record review and interviews during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to ensure that the binding arbitration agreement provides for the selection of a venue that is convenient to both parties. This was evident in 3 (Resident #36, #141, and #289) of 38 total sampled residents. Specifically, the Binding Arbitration Agreement signed by Residents #36, #141, and #289 did not contain documented evidence that the agreement addresses the selection of a venue that is convenient to both parties.

Inspectors wroteBased on record review and interview conducted during the Recertification survey from 3/9/23 and 3/16/23, the facility did not ensure that resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Specifically, the Comprehensive Care Plans (CCPs) for residents with significant weight loss were not updated and revised. This was evident for 3 of 6 residents reviewed for Nutrition out of 38 sampled residents. (Residents #18, #17, and #22,). The finding is: The facility Policy for Comprehensive Care Planning dated 11/1997, last revised 01/2023 documented that A Comprehensive Care Plan for each resident shall be developed through an interdisciplinary team approach. [...]

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey from 3/9/23 to 3/16/23, the facility did not ensure that comprehensive person-centered care plans were developed and implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment for 2 of 10 residents (Resident #26, Resident #29) reviewed for Accidents out of a total sample of 38 residents. Specifically, a Comprehensive Care Plan (CCP) had not been developed for safety measures related to smoking for Resident #26 and Resident #29.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, the facility did not effectively monitor a resident that was at risk for weight loss and weight fluctuations with a weight loss of 19.08 % in 6 months, and 5.09% in less than 1 month. This was evident for 1 of 6 residents reviewed for Nutrition out of a sample of 38 residents investigated. (Resident # 22).

Inspectors wroteBased on observation, record review and interview conducted during the Recertification survey from 3/9/23 to 3/16/23, the facility did not ensure that the medical care of each resident was supervised by a physician. Specifically, there was no documented evidence that the physician monitored changes in the resident's health status and provided interventions to address a resident's undesired significant weight loss over the period of 6 months. This was evident for 1 of 6 residents reviewed for Nutrition out of a sample of 38 residents investigated. (Resident # 22) The finding is: The facility's policy titled Physician dated 09/2016, last revised 02/2023, documented: Resident will be seen by Primary Physician/ Nurse Practitioner on Admission/ Readmission; Monthly (every 28-30 days); Significant Change; [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification survey conducted from 3/9/23 to 3/16/23, the facility did not ensure that a Medication Regimen Review (MRR) performed by the Consultant Pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This was evident for 2 of 5 residents (Resident #26 and Resident #71) reviewed for Unnecessary Medications Review out of a total sample of 38 residents. Specifically, 1). the physician did not act upon the consultant pharmacist's recommendations to attempt a gradual dose reduction (GDR) for residents receiving antidepressant medication, and 2). A pharmacy consultant recommendation for a Psychiatry consult to evaluate symptoms of depression and the therapeutic goals of Cymbalta was not completed.

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification survey from 3/9/23 to 3/16/23, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, blood pressure (BP) cuffs were not cleaned/disinfected after use between residents. This was evident for 2 out of 6 licensed nurses observed during the Medication Administration task.

Inspectors wroteBased on record reviews and interviews conducted during the recertification survey, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected the resident's current medical status. Specifically, a resident who had been on hemodialysis 3 times per week since 07/18/19 was not coded as a dialysis resident. This was evident for 1 of 38 sampled residents (Resident # 115). The finding is: Resident #115 had diagnoses which include End Stage Renal Disease. The MDS assessment dated [DATE] did not identify that the resident was receiving dialysis. Section O (Special Treatments, procedures, and programs), item J was left bank. The Physician's orders, initiated 7/18/19 and last renewed 2/16/20, documented orders for Hemodialysis 3 times per week on Monday-Wednesday-Friday. [...]

Inspectors wroteBased on observation, record review and interview conducted during the Recertification survey and abbreviated survey (NY00250178), the facility did not ensure that a resident received adequate supervision to prevent accidents. Specifically, a resident who required a Hoyer lift with 2-person assist for transfers was transferred with one-person assist. The resident sustained a hip fracture. This was evident for 1 out of 4 residents reviewed for accidents within a total sample of 39 (Resident #71).

Inspectors wroteBased on observation, record review, and staff interviews conducted during the re-certification survey, the facility did not ensure a resident with limited range of motion received treatment and services to increase and/or to prevent further decrease in range of motion. Specifically, a resident with physician's orders for Range Of Motion (ROM) exercises to Bilateral Upper Extremities 5-6 times per week for 15 minutes and Bed mobility exercises 6 times per week for 15 minutes were not provided. This was evident for 1 of 2 residents reviewed for Limited Range of Motion (Resident #57). The finding is: The facility policy and procedure titled Specific protocols and Guidelines for performing Range of Motion (ROM) dated 2/2019 documented that the Active Range of Motion exercise (AROM) is conducted by staff giving directions, cues, and/or demonstration to residents. [...]

Inspectors wroteBased on interviews and record review during an survey the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices that were complete and accurately documented for each resident. Specifically, Nursing Staff documented completion of Range of Motion exercises on several occasions in the medical record when they were not being provided. This was evident for 1 of 2 residents reviewed for Limited Range of Motion (Resident #57) The finding is. Resident # 57 had diagnoses which include Generalized Osteoarthritis and Depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required total assistance with transfer and toilet use, and extensive assistance with bed mobility, dressing, and personal hygiene. [...]