Via Christi Village Manhattan, Inc

Inspectors wroteBased on record review and interview, the facility failed to inform Resident (R)1 about the potential of non-coverage and the option to continue services with the beneficiary accepting liability for those services when staff failed to provide the CMS 10055, Advanced Beneficiary Notice (ABN), in a timely manner to Resident (R) 1's representative.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident (R) 54 and R4 and their representatives received a written notification of transfer that included a statement of the residents' appeal rights and the state ombudsman information, as soon as practicable upon their emergent transfer to the hospital.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide tube feeding management services consistent with the standards of practice when staff failed to verify placement of the feeding tube before administering medications and nutritional feeding for Resident (R) 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician and follow the standing orders for Resident (R) 17's low blood sugar levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications when staff failed to discard Resident (R)3 insulin (a hormone that lowers the level of glucose in the blood) outdated flex pen.

Inspectors wroteThe facility identified a census of 89 residents, with three residents reviewed for medication errors. Based on record review, observation and interview, the facility failed to ensure Resident (R) 1 remained free from significant medications errors. On 02/04/26, Certified Medication Aide (CMA) R administered R1 another resident's medications, which included multiple medications that affected the central nervous system and had psychotropic qualities including Paxil (antidepressant), lorazepam (antianxiety), tizanidine (muscle relaxant), and clozapine (antipsychotic), as well as other medications including Cardizem (antihypertensive), metformin (diabetic medication), and furosemide (diuretic). At around 08:30 AM, R1 reported to Licensed Nurse (LN) G she felt she had received the wrong medication. [...]

Inspectors wroteThe facility identified a census of 87 residents, with three residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility staff failed to ensure two staff safely transferred Resident (R)1 with a full mechanical lift as care planned. On [DATE] at 01:20 PM, CNA M was transferring R1 into her wheelchair with the full mechanical lift (Hoyer), without the assistance of the required second staff member. During the transfer, the bottom left sling loop came off the Hoyer lift, causing R1 to fall to the ground. Due to CNA M not following R1's care plan, R1 fell, broke her right distal femur, had extreme pain untreated by pain medication, and subsequently died. [...]

Inspectors wroteThe facility identified a census of 91 residents, with 3 residents sampled for medication errors. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 received treatments and care in accordance with professional standards of practice. On 03/22/25 at 10:30 AM, Certified Medication Aide (CMA) R assisted R1 in undressing in the bath spa and noted extensive purple/black bruising to R1's bilateral (both sides) axilla (armpit), bilateral arms, torso, and back. CMA R reported her findings to Licensed Nurse (LN) G, who assessed R1 and documented the extensive bruising. LN G then reported the findings to the nurse manager on duty, LN H. [...]

Inspectors wroteThe facility had a census of 86 residents. The sample included 20 residents, with two reviewed for dignity. Based on observation, record review, and interview, the facility failed to provide dignity and quality of life for Resident (R)187 and R133, by having an uncovered urinary collection bag visible to guests and other residents. This placed the residents at risk of embarrassment and an undignified living environment.

Inspectors wroteThe facility had a census of 86 residents. The sample included 20 residents with four residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review the facility failed to revise the care plan for Resident (R) 5 who was on Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). This deficient practice placed R5 at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 86 residents. The sample included 20 residents of which one was reviewed for discharge. Based on record review and interview, the facility failed to provide a resident-specific detailed discharge summary and complete a recapitulation (summary) of stay for Resident (R) 233. This placed the resident at risk for unidentified and unmet care needs.

Inspectors wroteThe facility had a census of 86 residents. The sample included 20 residents with three reviewed for urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review the facility failed to provide catheter care and services consistent with the standards of practice for Resident (R) 133 when staff failed to monitor urine output, failed to ensure the tubing was anchored appropriately, and failed to manage the tubing and urine collection bag in a sanitary and dignified manner. This placed the resident at risk for catheter-related complications including dislodgement and urinary tract infections (UTI).

Inspectors wroteThe facility had a census of 86 residents. The sample included 20 residents with one reviewed for hydration. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 57's physician-ordered fluid restriction. This placed R57 at risk of complications related to fluid overload.

Inspectors wroteThe facility had a census of 86 residents. Based on observation, record review, and interview the facility failed to adhere to infection control for enhanced barrier precautions (EBP -an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities), for Resident (R)5, who had an open wound on her right calf. This placed the resident at risk for infection.

Inspectors wroteThe facility identified a census of 80 residents with three residents reviewed for medication errors. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from significant medication errors. On 12/07/23 R1 admitted to the facility with a physician's order for glimepiride (medication used to lower blood glucose [sugar] levels) 2 milligrams (mg) twice daily. Staff incorrectly transcribed the order as glimepiride 4 mg twice daily. R1 received a total of seven doses of glimepiride, at twice the prescribed dosage, before staff caught the error on 12/11/23 at 09:30 PM. Staff did not check R1's blood sugar but notified R1's representative and primary care physician (PCP) and stated there were no adverse effects from the error. [...]

Inspectors wroteThe facility identified a census of 80 residents with three residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to ensure staff repositioned Resident (R)2 safely while in her Broda chair (specialized wheelchair with the ability to tilt and recline) and R2 sustained a right proximal (nearer to a point of reference or attachment) humerus (upper arm bone) fracture (broken bone). This deficient practice also placed R2 at risk for pain.

Inspectors wroteThe facility identified a census of 85 residents. The sample included three residents. Based on observations, record review, and interviews, the facility failed to provide a safe environment free from preventable accidents for Resident (R) 1 and R2. On 10/14/23 Certified Medication Aide (CMA) R picked R1 up from the emergency room (ER) using the facility transportation van. CMA R assisted R1, who used a wheelchair, into the van. CMA R failed to secure the two front straps as well as the lap strap. As CMA R made the first left hand turn after leaving the hospital, R1's wheelchair tipped backward, and R1 fell from the chair and hit his head. R1 returned to the ER where he was diagnosed with a fracture of the cervical vertebrae (neck spine). [...]

Inspectors wroteThe facility had a census of 83 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure staff possessed the appropriate competencies to safely administer medications per the standards of practice when a licensed nurse administered Resident (R) 14 medications without reviewing R14's Medication Administration Record (MAR) verifying that the resident's morning medications had not already been given. Additionally, Certified Medication Aide (CMA) R set up all the residents in Court-C's medications and left them in the medication cart drawer to be administered at a later time. This placed the resident's at risk for medication errors.

Inspectors wroteThe facility had a census of 83 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)61, R33 and R231's insulin (hormone which allows cells throughout the body to uptake glucose) flex pen with the date opened and expiration date, failed to label R61's open insulin with her name, the date opened, and expiration date. The facility further failed to calculate R57 ' s expiration date from the date opened accurately. These deficient practices placed the affected resident at risk for ineffective medications.

Inspectors wroteThe facility had a census of 83. The sample included 18 residents. Based on record review, interview, and observation the facility failed to treat residents with respect, dignity, and privacy during blood glucose testing and insulin (hormone that lowers the level of glucose in the blood) administration. This placed the resident at risk for impaired psychosocial wellbeing.

Inspectors wroteThe facility had a census of 83 residents. The sample included 18 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 14's PRN (as needed) clonazepam did not have a stop date, placing the resident at risk for unnecessary psychotropic (alters mood or thought) medications.

Inspectors wroteThe facility has a census of 83 residents. The sample included 18 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to place a stop date on Resident (R) 14's as needed (PRN) clonazepam (a class of medication used to treat anxiety, panic attacks, and seizures). This placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications and related complications.

Inspectors wroteThe facility had a census of 83 residents. The sample included 18 residents. Based on record and interview, the facility failed to prevent a medication errors when a licensed nurse administered Resident (R) 14 medications without reviewing the Medication Administration Record (MAR) and verifying that the resident's morning medications had not already been given which resulted in a medication error. This placed the resident at risk for complications and physical decline from and overdose of medications.