Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Via Christi Village Manhattan, Inc during CMS and state inspections, most recent first.
Transfer notices for two residents were incomplete when they were emergently sent to the hospital for a higher level of care. The scanned discharge/transfer forms documented that the residents and their representatives were notified, but the forms did not include the required statement of appeal rights or State Ombudsman contact information, despite the facility policy requiring those details in the written notice.
Failure to verify feeding tube placement before administering enteral nutrition and meds. A resident with dysphasia, cerebral infarct, moderate cognitive impairment, and a feeding tube had a care plan and MD order directing staff to check tube placement before each feeding and medication pass. An LPN gave Jevity and water flushes, and later crushed meds with water flushes, without assessing placement or checking residuals before administration.
A resident with dementia, DM, heart failure, and severe cognitive impairment had repeated low blood glucose readings, including several below 70 mg/dL. The EMR showed insulin aspart was sometimes held and sometimes given despite low readings, but there was no documentation that the hypoglycemia standing orders were carried out or that the PCP was notified. Staff interviews showed confusion about when to call the physician and how to interpret the standing orders.
Outdated insulin was found on a treatment cart when a resident’s Novolog flex pen was observed with an expired discard date. An LPN confirmed outdated insulin flex pens should be discarded, and an Administrative Nurse confirmed staff should check insulin pens for expiration dates and discard expired ones.
A resident with anxiety, CAD, depression, DM, and significant ADL needs received another resident's medications from a CMA who was reportedly distracted and preoccupied while passing meds near the breakfast table. After noticing a fish oil capsule she did not take, the resident reported concern to an LN, but the CMA insisted the meds were correct, and only informal monitoring by a CNA was initiated. About an hour later, the resident was found lethargic, minimally responsive, and slurring speech, leading to STAT Narcan and epinephrine administration and transfer to the ER, where she was diagnosed with an unintentional overdose from multiple centrally acting psychotropic and other medications and admitted to the ICU.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with severe cognitive impairment and on Coumadin developed extensive bruising, which was observed by staff and documented, but the physician was not notified as required by protocol. Staff continued to administer Coumadin for several days despite the bruising, and the resident was later found to have a critically elevated INR. Facility procedures for anticoagulant management and physician notification were not followed.
The facility failed to maintain the dignity of two residents by not covering their urinary catheter bags, which were visible to others. One resident with heart and kidney failure was observed with an uncovered catheter bag in their room, while another resident with a UTI and brain injury had an uncovered bag in the dining room. This was against the facility's policy, as confirmed by an administrative nurse.
A facility failed to update a resident's care plan to include Enhanced Barrier Precautions (EBP) for infection control. The resident, with a history of stroke, diabetes, and osteoporosis, had a Stage 2 pressure ulcer and required staff assistance for daily activities. Despite a sign indicating the need for PPE, a nurse entered the resident's room without full PPE, unaware of the requirement. The care plan lacked EBP instructions, risking impaired care due to uncommunicated needs.
A resident with complex medical needs was discharged without a complete discharge summary and recapitulation of stay due to a mix-up caused by a cyber-attack on the facility's electronic records. The resident's medical history included a pelvic fracture, diabetes, peripheral vascular disease, end-stage renal disease, and a right below-knee amputation. The facility's policy required a detailed discharge summary, which was not provided, placing the resident at risk for unmet care needs.
A resident with an indwelling suprapubic catheter and nephrostomy tube did not receive appropriate catheter care, as staff failed to monitor urine output consistently and manage the catheter tubing and collection bag in a sanitary manner. The catheter bag was observed on the floor and uncovered, contrary to facility guidelines, placing the resident at risk for complications.
A facility failed to monitor a resident's physician-ordered fluid restriction, risking fluid overload complications. The resident had conditions like CHF and diabetes, requiring a 2000 ml fluid limit. Staff were unaware of the restriction specifics, and the resident's meal ticket lacked this information. Interviews revealed a lack of communication and awareness among staff, leading to the deficiency.
A facility failed to follow infection control protocols for enhanced barrier precautions for a resident with an open wound. A nurse entered the resident's room, which had clear instructions for PPE use, but only wore gloves while handling the wound. This oversight was confirmed through interviews, and the facility's policy requires full PPE during high-contact care to prevent the spread of multidrug-resistant organisms.
Transfer Notices Missing Required Appeal and Ombudsman Information
Penalty
Summary
The facility failed to ensure that Resident 54 and Resident 4, and their representatives, received a written transfer notification that included a statement of appeal rights and State Ombudsman information when they were emergently transferred to the hospital for a higher level of care. For Resident 54, the electronic medical record contained a scanned Discharge/Transfer, Room Change, Roommate Notice form dated 11/30/25 showing the resident and representative were notified, but the form did not include the required appeal rights statement or Ombudsman information. A similar issue was identified for Resident 4. The electronic medical record contained a scanned Discharge/Transfer, Room Change, Roommate Notice form dated 02/17/26 documenting transfer to the hospital for a higher level of care and that the resident and representative were notified, but the form also lacked the statement of the right to appeal and the State Ombudsman information. Social Services and Administrative Staff stated they were not aware the discharge/transfer form had to include those items, and the facility policy required written notice to include the reason for transfer, effective date, destination, appeal rights information, bed-hold policy, and State Long-term Care Ombudsman contact information.
Failure to Verify Feeding Tube Placement Before Feedings and Medications
Penalty
Summary
The facility failed to provide tube feeding management services consistent with the standards of practice for a resident with a feeding tube when staff did not verify feeding tube placement before giving medications and nutritional feeding. The resident had diagnoses of dysphasia and cerebral infarct, a Brief Interview Status of 11 indicating moderate cognitive impairment, and required staff assistance with multiple activities of daily living. The resident’s care plan, dated 04/03/26, directed staff to administer tube feedings per physician order and to assess tube placement, patency, and placement before each feeding by two means. It also identified the resident as high risk for tube feeding dislodgement and aspiration and directed staff to check the tube to ensure it was patent and in the correct placement. The physician order dated 04/17/26 directed Jevity 1.5 calorie per ml, 8 oz per feeding tube three times daily, and ordered crushed medications to be dissolved in water with specified water flushes before, between, and after medications. On 4/27/26, a licensed nurse administered water and 4 oz of Jevity, then more water, without assessing placement or checking stomach residual before the nutritional supplement. On 4/28/26, the same nurse crushed and administered medications with water flushes but did not assess or listen for placement or check stomach residual before medication administration. On 04/30/25, an administrative nurse verified that nursing staff were to check placement prior to administering medications and feedings and stated an in-service would be provided regarding the feeding tube protocol. The facility policy stated staff caring for residents with feeding tubes should be trained to recognize and report complications, and that aspiration risk may be affected by failure to confirm placement before initiating feeding.
Failure to Follow Hypoglycemia Standing Orders and Notify Physician
Penalty
Summary
The facility failed to notify the physician and follow the standing orders for a resident with dementia, type 2 diabetes mellitus, heart failure, major depressive disorder with recurrent severe psychotic symptoms, and severe cognitive impairment. The resident’s care plan directed staff to perform fingerstick blood sugars per physician orders, obtain HbA1c or other labs per orders, administer medications as ordered, monitor side effects, and notify the physician as needed. The physician standing orders for hypoglycemia directed staff to treat blood glucose levels below 70 mg/dL with 15 grams of simple carbohydrates, recheck the blood glucose in 15 minutes, repeat treatment and call the PCP if the level remained below 70 mg/dL, and continue checking every 15 minutes until the blood glucose was greater than 70 mg/dL. The resident’s April 2026 TAR showed multiple morning blood sugar readings below 70 mg/dL, including 59, 54, 62, 60, 68, 58, and 68 mg/dL. The record also showed that insulin aspart 2 units SQ before breakfast was ordered, with instruction to ensure the resident ate before administration. On several dates when the blood sugar was below 70 mg/dL, insulin was not given, and on other dates insulin was given despite low readings. The EMR lacked evidence that the standing-order treatment was implemented and lacked documentation that the physician was notified for blood sugar levels below 70 mg/dL or when staff held insulin. During interview, a licensed nurse stated that if the physician had parameters, they would be included in the orders and placed on the electronic medication and treatment records, and she was unsure whether the physician should have been called for the resident’s low blood sugar readings. An administrative nurse stated staff were to call if the resident was symptomatic and believed the order meant staff should give a protein or simple carbohydrate if symptomatic. A consultant stated the staff should have notified the practitioner of blood sugar levels below 70 mg/dL and noted the resident used a continuous glucose monitoring system that could be off by about 14 points, with less accurate levels below 100, and that a fingerstick would have been done to verify the level if staff had been notified.
Outdated insulin flex pen found on treatment cart
Penalty
Summary
The facility failed to properly store medications when staff did not discard Resident 3’s outdated Novolog insulin flex pen. During observation of the F Court treatment cart, Resident 3’s Novolog flex pen was found labeled with an open date and a discard date that was 10 days expired. A License Nurse verified that nurses should discard outdated insulin flex pens, and an Administrative Nurse verified that nurses should check insulin flex pens for expiration dates and discard them if expired. The report also cited the facility’s Storage of Medications policy, which states that drugs and biologicals are to be stored in a safe, secure, and orderly manner and that medication carts and medication rooms are routinely inspected for discontinued, outdated, defective, or deteriorated medications.
Significant Medication Error Leading to Resident Overdose and ICU Admission
Penalty
Summary
The deficiency involves a failure to ensure a resident remained free from significant medication errors when a certified medication aide (CMA) administered another resident's medications. The resident had diagnoses including anxiety, coronary artery disease, depression, diabetes mellitus, and functional limitations requiring substantial assistance with activities of daily living. The resident used psychotropic medications for anxiety and depression, and her care plan directed staff to administer medications as needed and to monitor for drug-related complications and changes in depressive or behavioral symptoms. On the morning of the incident, the resident received her medications from the CMA while seated at a breakfast table next to another resident who shared the same first name and who did take fish oil. The resident later noticed a fish oil capsule in her medication cup, which she did not take as part of her prescribed regimen, and reported to a licensed nurse (LN) that she believed she had received the wrong medications. The LN questioned the CMA, who insisted she had given the correct medications and suggested she might have accidentally added fish oil to the resident's pills. The LN then instructed a certified nurse aide (CNA) to keep an eye on the resident, and the CNA checked the resident approximately 30 minutes later, finding her alert, oriented, and with vital signs within normal limits. Around an hour after the initial concern, the LN went to the resident's room to provide care and found her lethargic, minimally responsive, and slurring her words. Another LN was called to assist with assessment, and the provider was notified and ordered STAT Narcan and epinephrine, which were administered with minimal response before 911 was called. Emergency medical services were informed of the possible erroneous medication administration, and the resident was transferred to the emergency room, where she was documented as having been accidentally given another resident's medications, including multiple centrally acting psychotropic and other medications. She was diagnosed with a primary unintentional overdose and admitted to the intensive care unit. Later, upon readmission to the facility, the resident reported a gap in memory of the events, expressed fear and distress about not knowing what had happened, and described unsettling dreams, while also recounting that the CMA had appeared distracted and preoccupied with personal issues at the time of the medication pass.
Removal Plan
- Removed CMA R from the medication cart and terminated her employment.
- Evaluated all residents residing on A and B neighborhoods (where CMA R administered meds) for adverse reactions and report any ill effects to their PCP.
- Performed an audit for residents with the same name and placed bright pink "Same Name" labels on the med cards to alert staff.
- Conducted audits of the med cards.
- Re-educated all clinical staff on Same Name Alert, the 5 rights of medication administration, and avoiding distractions during medication administration.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Notify Physician and Hold Anticoagulant After Signs of Excessive Bruising
Penalty
Summary
A resident with a history of anticoagulant use, severe cognitive impairment, and high fall risk was observed to have extensive purple and black bruising on both axillae, arms, torso, and back during a routine bath. The Certified Medication Aide who discovered the bruising reported it to the Licensed Nurse, who assessed and documented the findings, and then informed the nurse manager. Despite the resident being on Coumadin, neither the Licensed Nurse nor the nurse manager notified the primary care physician of the extensive bruising as required by facility protocol before administering the next dose of anticoagulant. Following the discovery of the bruising, staff continued to administer three additional doses of Coumadin to the resident over the next three days. The resident's care plan and facility protocol specifically directed staff to monitor for signs of bleeding and to immediately notify the physician of any such findings in residents on anticoagulants. The failure to notify the physician and to hold the medication as per protocol resulted in the resident receiving further doses of Coumadin despite clear signs of excessive bruising. The resident's condition was later found to be associated with a critically elevated INR, which was only identified after further investigation and laboratory testing. Staff interviews confirmed that the protocol for anticoagulant management was not followed, and the required physician notification did not occur at the time the bruising was first observed. The facility's own procedures outlined the need for prompt communication with the physician in such cases, but this was not carried out, leading to a deficiency in providing care according to professional standards of practice.
Failure to Maintain Resident Dignity by Covering Urinary Catheter Bags
Penalty
Summary
The facility failed to uphold the dignity and quality of life for two residents, R187 and R133, by not covering their urinary catheter bags, which were visible to other residents and guests. R187, who had diagnoses including heart failure, kidney failure, and a lumbar spine fracture, was observed on two occasions with an uncovered urinary catheter bag hanging on the side of the bed, visible from the door. The facility's policy, which mandates that urinary catheter bags should be covered to maintain dignity, was not followed, as confirmed by Administrative Nurse D. Similarly, R133, who had a UTI, neuromuscular dysfunction of the bladder, and a traumatic brain injury, was observed with an uncovered urinary catheter bag while being assisted by a CNA. The catheter bag was visible to other residents in the dining room, contrary to the facility's policy. Administrative Nurse D confirmed that the catheter bag should have been covered to protect the resident's dignity. These observations indicate a failure to adhere to the facility's Quality of Life-Dignity policy, which emphasizes the importance of maintaining resident dignity and privacy.
Failure to Revise Care Plan for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R5, who was on Enhanced Barrier Precautions (EBP) for infection control. R5's medical history included a cerebrovascular accident affecting the right side, diabetes mellitus, and osteoporosis, with severely impaired cognition and dependency on staff for all activities of daily living. The resident had a Stage 2 pressure ulcer, and the care plan directed staff to maintain skin integrity and assist with repositioning. However, the care plan did not include any instructions regarding EBP, which are critical for infection control. During an observation, a Licensed Nurse (LN) entered R5's room, which had a sign indicating the need for personal protective equipment (PPE) and a storage bin with PPE supplies. The LN donned only gloves and did not wear full PPE while attending to the resident's wound, which was draining. The LN was unaware of the requirement to wear full PPE in the isolation room. An interview with an Administrative Nurse confirmed that the care plan lacked documentation for EBP, placing R5 at risk for impaired care due to uncommunicated care needs.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a resident-specific detailed discharge summary and complete a recapitulation of stay for Resident 233. This deficiency was identified during a review of the resident's electronic medical record and interviews with facility staff. Resident 233 had a complex medical history, including a nondisplaced fracture of the left posterior column acetabulum, diabetes mellitus with circulatory complications, peripheral vascular disease, end-stage renal disease requiring dialysis, a right below-knee amputation, reduced mobility, and a need for assistance with personal care. The resident also had moderately impaired cognition, exhibited physical and verbal behaviors, and rejected care, which significantly interfered with their care and social interactions. The resident was dependent on staff for various activities of daily living and had severe pain and pressure injuries upon admission. On the day of discharge, the nurse responsible for completing the discharge instructions mixed up the discharge with another due to a cyber-attack on the facility's electronic records system. As a result, an incomplete discharge summary was provided to the resident's representative, lacking a recapitulation of the resident's stay. The facility's policy required a comprehensive discharge summary and post-discharge plan, including a recapitulation of the resident's stay, current diagnosis, medical history, and other relevant information. The failure to provide this information placed the resident at risk for unidentified and unmet care needs.
Inadequate Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate catheter care for Resident 133, who had an indwelling suprapubic catheter and nephrostomy tube. The resident's care plan required staff to monitor for signs of urinary tract infections (UTIs), provide catheter care per facility policy, and maintain a closed drainage system. However, the facility did not consistently monitor urine output, as documentation was missing for 31 of 75 shifts. Additionally, the catheter tubing was not anchored appropriately, and the urine collection bag was not managed in a sanitary and dignified manner, as it was observed lying on the floor and without a privacy cover. During an observation, a certified nurse aide stepped on the catheter tubing during a transfer, and the catheter bag was placed on the floor in the bathroom. The resident was then taken to the dining room with the catheter bag uncovered, making the urine visible to other residents. These actions were inconsistent with the facility's guidelines for preventing catheter-associated UTIs, which emphasize the importance of hand hygiene, keeping the drainage bag below the bladder level, and not placing it on the floor. The facility's failure to adhere to these standards placed the resident at risk for catheter-related complications, including dislodgement and UTIs.
Failure to Monitor Fluid Restriction for Resident
Penalty
Summary
The facility failed to monitor a resident's physician-ordered fluid restriction, placing the resident at risk of complications related to fluid overload. The resident, identified as R57, had multiple diagnoses including congestive heart failure, pulmonary hypertension, and diabetes mellitus, which necessitated a fluid restriction of 2000 milliliters per 24-hour period. The care plan specified that half of the fluid should be provided by nursing staff and the other half by dietary staff. However, the clinical record lacked evidence of staff monitoring and recording the resident's fluid intake. Observations and interviews revealed that staff were unaware of the fluid restriction specifics, and the resident's meal ticket did not include information about the restriction. Interviews with staff members, including a CNA, a licensed nurse, and dietary staff, indicated a lack of awareness and communication regarding the resident's fluid restriction. The CNA mentioned that meal intake and fluids were recorded in the EMR, but the licensed nurse was unsure how to access this information and did not know who was responsible for monitoring the fluid intake. The dietary staff was unaware of the fluid restriction, and the administrative nurse acknowledged that the fluid restriction was overlooked. The facility's policy required written notice of fluid restrictions to be communicated to the Nutrition and Dining Services department, but this was not followed, leading to the deficiency.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control protocols for enhanced barrier precautions (EBP) for a resident with an open wound on her right calf. During an observation, a licensed nurse entered the resident's room, which had a sign indicating the need for personal protective equipment (PPE) such as gowns and gloves. Despite the instructions, the nurse only donned gloves and proceeded to handle the resident's wound, which was draining serosanguineous fluid. The nurse acknowledged not wearing full PPE and was unaware of the requirement to do so. Interviews with the nurse and an administrative nurse confirmed that the resident's room had clear instructions for wearing appropriate PPE, and staff should have adhered to these guidelines. The facility's policy on enhanced barrier precautions, dated March 2024, mandates the use of gowns and gloves during high-contact care activities to prevent the transmission of multidrug-resistant organisms. The failure to follow these protocols placed the resident at risk for infection.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 30 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Manhattan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stoneybrook Retirement Community | 1.4 mi | ★★★★★ | 9 | 0 |
| Meadowlark Hills | 1.6 mi | ★★★★★ | 0 | 0 |
| Westy Community Care Home | 15.4 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Valley Vista | 15.4 mi | ★★★★★ | 0 | 0 |
| Leonardville Nursing Home | 17.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Via Christi Village Manhattan, Inc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.