Northern Manhattan Rehabilitation and Nursing Cent

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services. Specifically, the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal Staffing Data Report.

Inspectors wroteBased on observation, record review, and interviews, during the Recertification and Complaint (Intake 622067) Survey, the facility failed to notify a resident's representative of a significant change in the resident's status. This was evident for one (1) (Resident #43) of 40 sampled residents. Specifically, Resident #43's representative was not notified of the resident's change in condition that resulted to a hospital transfer on 10/17/2024.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a summary of the baseline care plan for two (2) (Residents #5 and #98) of 40 sampled residents. Specifically, Resident #98 and Resident #5's representative were not provided with a written summary of the residents' baseline care plan.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure that residents are free of any significant medication errors. This was evident for one (1) (Resident #324) of 8 residents reviewed during the Medication Administration Task. Specifically, Resident #324 was not administered the 10:00 AM dose of Dorzolamide-Timolol eye drops as ordered by the physician and a 2:00 PM dose of Hydralazine 50 milligrams was held without physician notification.

Inspectors wroteBased on observation, record review, and interviews , the facility did not ensure that drugs were stored in accordance with professional standards. This was evident in two (2) (Unit 3 and Unit 5) of nine (9) units observed for medication administration and medication storage. Specifically, Unit three (3) and Unit five (5) medication carts were left unlocked and unattended on 2 occasions.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards of food service safety. This was evident during Dining and Kitchen Observation Task. Specifically, 1.) Certified Nursing Assistant #8 failed to perform hand hygiene while assisting residents with their meals. 2.) Kitchen staff were observed with visible facial hair while in the kitchen area. 3.) Expired food items were observed in the kitchen refrigerator.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (622104 & 662084), the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. This was evident for two (2) of seven (7) residents (Residents #4 and #5) sampled. Specifically: 1. Resident #4 complained of pain to their left arm on 03/27/2025 and 03/28/2025. There was no documented evidence medical interventions were completed. On 03/31/2025, Resident #4 was transferred to the hospital with altered mental status and to rule out deep vein thrombosis (a blood clot forming in the deep vein). At the hospital, Resident #4 was diagnosed with a fracture of the left proximal humerus. This resulted in actual harm to Resident #4 that was not Immediate Jeopardy. 2. [...]

Inspectors wroteThe findings include:The facility's policy titled 'Pain Assessment' with a review date of 10/2005, directed that every resident will be assessed on admission for pain management and thereafter as medically indicated. Respectively, pain control measures should be used before pain becomes severe. It also directed that the physician was to be notified if measures are unsuccessful or if current complaint is a significant change from the resident's experience. The facility's policy titled 'Change in Resident's Condition', with a review date of 03/2022, directed staff to document any change in a resident's condition and to inform the Medical Doctor and designated representative in a timely fashion. The policy also documented that the resident is placed on the 24-hour report and care is rendered according to need and Medical Doctor's order. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated survey (6220995), the facility did not ensure a resident was free from abuse. This was evident for one (1) of four (4) residents (Resident #7) sampled. Specifically, on 03/05/2025 at 6:30 PM, Resident #7 reported to Licensed Practical Nurse #1 that they were hit with a bottle on their upper lip by Certified Nursing Assistant #9. Resident #7 was assessed by the Director of Nursing on 03/05/2025 and was observed with slight swelling to their upper lip.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (622104), the facility did not ensure that a resident care plan was reviewed and revised by the interdisciplinary team. This was evident for one (1) out of seven (8) residents sampled (Resident #4). Specifically, Resident #4 reported to Certified Nursing Assistant #3 that they had pain in their left arm on 03/27/2025, just before lunch, and Registered Nurse #4 was notified. Resident #4 complained of pain their left arm again on 03/28/2025 and the left arm was observed to be swollen and larger than the right. Registered Nurse #4 notified Physician #1 who ordered Tylenol (1000 milligrams) and a STAT x-ray. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (622104), the facility did not ensure licensed nurses have the specific competencies, and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This was evident for one (1) of seven (7) residents (Resident #4) reviewed. Specifically, Resident #4 complained of pain to their left arm on 03/27/2025 and 03/28/2025. Physician #1 was notified on 03/28/2025 and ordered Tylenol 1000 milligrams and a STAT x-ray of the left arm. Registered Nurse #4 stated they did not enter the orders because they did not receive training on the electronic medical record (Sigma). This resulted in a delay in treatment for Resident #4 who was transferred to the hospital on [DATE] at 1:55 PM and was admitted with diagnosis of left arm fracture.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00339715), the facility failed to protect a resident from physical abuse by nursing home staff. This was evident in one out of ten residents sampled for abuse (Resident #1). Specifically, on 04/19/2024 at 8:30 pm, Certified Nursing Assistant #1 and Certified Nursing Assistant #2 were providing Incontinence care to Resident #1. Certified Nursing Assistant #2 witnessed Certified Nursing Assistant #1 slap Resident #1 several times in the head. On 04/19/2024 at 9:30 pm, Registered Nurse #1 did a physical assessment on Resident #1 and there were no bruises. Subsequently, on 04/20/2024 at 7:00 am, the Director of Nursing did a physical assessment of Resident #1 and saw a red bruise measuring 2 centimeters by 1.5 centimeter under Resident #1's left eye. [...]

Inspectors wroteBased on record review and interviews conducted during an abbreviated survey (NY00339715), the facility did not ensure that all allegations of abuse were reported in a timely manner to local law enforcement, facility administrator, and the New York State Department of Health in accordance with federal and state regulations. This was evident in one out of ten residents sampled (Resident #1). Specifically, on 04/19/2024 at 8:30 pm, Certified Nursing Assistant #2 reported to License Practical Nurse #1 that Certified Nursing Assistant #1 slapped Resident #1 several times in the head. On 04/19/2024 at 11:59 pm, The Director of Nursing notified the facility's Administrator by a text message about the incident. On 04/20/2024 at 12:44 am, the facility failed to report the allegation to law enforcement and the New York State Department of Health within two hours.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 11/27/2023 to 12/01/2023, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident for 6 of 8 resident floors (Floor 2, 4, 5, 6, 7, and 9) and the kitchen. Specifically, 1) ice machines in the pantry on Floors 2, 4, 5, 6, 7, and 9 were dirty and dusty, and 2) the kitchen had dusty air vents and walls.

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey from 11/27/2023 to 12/01/2023, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident for 6 of 8 resident floors (Floors 4, 5, 6, 7, 8, and 9) during review of the Environment. Specifically, 1) Air Conditioning/Heating (AC/H) units were observed with missing covers leaving the inside of the unit exposed, 2) cabinets were in disrepair with misaligned, cracked doors and shelves and missing doorknobs, and 3) a cracked bedside table and cracked tile in room [ROOM NUMBER].

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification and complaint (NY00323859) survey from 11/27/2023 to 12/01/2023, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice. This was evident for 1 (Resident #241) of 37 total sampled residents. Specifically, the Registered Nurse (RN) and the Medical Doctor (MD) were not made aware in a timely manner when Resident #241 had a change in condition and required hospitalization.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 11/27/2023 to 12/01/2023, the facility did not ensure medications and biologicals were stored in accordance with currently accepted professional principles. This was evident for 1 (5th Floor) of 8 resident units. Specifically, the 5th Floor medication room contained an expired bag of intravenous (IV) fluids.

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification survey from 11/27/2023 to 12/01/2023, the facility did not ensure that infection control practices were maintained. This was evident for 1 (Resident #216) of 37 total sampled residents. Specifically, Registered Nurse (RN) #2 was observed during wound care did not perform hand hygiene before wound care or during wound care at required intervals when doing wound care on a resident.

Inspectors wroteBased on interviews and record review during an abbreviated survey (NY00291550), the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations of abuse were made to the New York State Department of Health (NYSDOH). This was evident in 2 of 13 residents reviewed (Resident #6 and Resident #7) for abuse. Specifically, On 02/20/22 at 1:55 AM, Resident #6 and Resident #7 were involved in an alleged resident to resident physical abuse, the facility reported the incident to the NYSDOH on 02/20/2022 at 2:41 PM.

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey, 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, 1) Oxygen tubing was observed on multiple occasions touching the floor (Resident #508 and #509). 2) The facility did not have a functional, site-specific water management plan, sampling plan, or a completed and up-to-date environmental risk assessment for Legionella. This was evident for 2 of 3 residents observed for Respiratory care (Resident #508 and #509) out of an investigative sample of 40 residents and investigation of facility task Infection Control for Legionella.

Inspectors wroteBased on observations, record review, and staff interviews during the recertification survey, the facility did not ensure that the resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Specifically, 1) A resident room was observed with multiple boxes on the floor from head of bed to the foot of the bed, boxes under elevated bed head, multiple plastic containers stacked up at the back of the bed headboard from the floor to over top of bedhead, multiple filled plastic bags observed under bed, covering the entire space under the bed and multiple tied filled plastic bags observed under the air conditioner in the room (Resident #100), and multiple privacy curtains observed dirty with stains (rooms [ROOM NUMBER]). [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey, the facility did not ensure that a resident's assessment was accurate. Specifically, the Minimum Data Set (MDS) 3.0 assessment for a Resident inaccurately documented dialysis treatment. This was evident for 1 out of 3 residents (Resident #102) reviewed for Resident Assessment out of an investigative sample of 40 residents.

Inspectors wroteBased on observations, staff interviews and record reviews conducted during the recertification survey, the facility did not ensure that a person-centered comprehensive care plan developed and implemented to meet their preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs of residents. Specifically, 1) A Care Plan with measurable goals and interventions were not developed for a resident who room was observed with multiple boxes from the head of bed to the foot of the bed, boxes observed under elevated bed head, multiple plastic containers observed stacked up at the back of the bed from floor to top of bed head, filled plastic bags observed under bed, under air conditioner in the resident room (Resident #100). 2) A Care Plan with measurable goals and interventions were not developed for a resident with Pressure Ulcer/Injury (Resident # 355). [...]

Inspectors wroteBased on interviews and record reviews during the Recertification and Abbreviated Survey (#NY00260357) the facility did not ensure the resident and/or resident representative participated in care planning, to the extent practicable. Specifically, residents were not invited to the quarterly CCP meeting. This was evident for 2 of 40 sampled residents (Resident #s 187 and 296).

Inspectors wroteBased on observations, record review and interviews conducted during a recertification survey, the facility did not ensure that care and treatment were provided to a resident, in accordance with comprehensive assessment and professional standards of practice. It was determined that the facility did not ensure that a resident was treated for a UTI in a timely manner. Specifically, Resident # 203 had lab results, abnormal Urinalysis complete with microscopy, dated 08/28/21, and the results were not reviewed, and treatment ordered until 09/21/21, by the Physician. This was evident for 1 of 1 resident reviewed for UTI (Resident #203)

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that an appropriate environment and atmosphere plan were in place that was conducive to a resident's mental and psychosocial well-being; and the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, a resident with hoarding behaviors was not addressed. This was evident for 1 of 1 resident reviewed for Behavior/Emotional. (Resident #100).

Inspectors wroteBased on observation, record review, and staff interview conducted during the Recertification survey, the facility did not ensure expired syringes were identified and removed from the current medication supply for disposition. Specifically, expired insulin and supplements were observed in the medication carts. This was evident on 1 of 8 units reviewed for Medication Storage (Unit 4). The finding is: The policy Medication Storage and Handling, last reviewed 11/20, documented medication biologicals and intravenous sections having an expiration date are removed from storage and usage and properly disposed of after such date. No discontinued, outdated, or deteriorated drugs or biologicals are to be used for residence care. All such drugs are to be returned to the pharmacy for destruction. [...]

Inspectors wroteBased on observations, record review and interviews, during the Recertification survey the facility did not ensure each resident received food that accommodated residents allergies, intolerance's, and preferences. Specifically, (1). A resident who expressed a preference for no raw cucumber, raw onion and raw tomato and whose meal ticket specified such, was served these items at the lunch meal on a vegetable salad and then served raw onion and raw tomato on a chicken sandwich during the lunch meal. (2). A resident who expressed a preference for no tomato was served tomato soup at a lunch meal and sliced raw tomato with a chicken sandwich at a lunch meal. This was evident for 2 of 26 residents sampled for dining observations. (Resident #260 and Resident #267).