Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Northern Manhattan Rehabilitation And Nursing Ctr during CMS and state inspections, most recent first.
Insufficient nursing staffing and licensed nurse coverage were identified after PBJ data and staffing sheets showed multiple shifts with callouts and no replacements, including shifts with no nurse on a unit and nights with only one CNA on high-acuity units. Records showed many residents on those units required 2-person assist for transfers and bed mobility, while interviews confirmed staffing shortages and that staff sometimes struggled to provide care with only 3 CNAs.
A resident with multiple diagnoses, including dementia, experienced a significant change in condition and was transferred to the hospital without timely notification to their representative. Facility staff and documentation confirmed that the family was only informed after the resident returned, contrary to facility policy requiring immediate notification of such events.
Two residents, one with heart failure and peripheral vascular disease and another with cerebrovascular accident and heart failure, did not receive written summaries of their baseline care plans within 48 hours of admission as required. Documentation was lacking, and interviews revealed staff confusion about responsibility for providing and documenting the care plan summaries.
A resident with glaucoma and HTN had a scheduled glaucoma eye drop dose missed when an LPN became confused by the resident’s questions, delayed the dose, and then forgot to return to give it. The same resident also had a scheduled hydralazine dose held by an LPN because of a BP reading of 119/53, even though the resident had no signs or symptoms of hypotension, and there was no documented evidence that the MD was notified.
Unlocked Medication Carts Left Unattended: An LPN left a medication cart unlocked and unattended while administering insulin to a resident, and another LPN left a medication cart unlocked with a drawer open while giving medication to another resident. The DON stated that medication carts should be locked when left in the hallway and that leaving them open and unattended is a safety issue.
Food service safety standards were not followed when a CNA assisted residents with meals and other tasks without performing hand hygiene, kitchen staff were observed with visible facial hair not properly covered in food prep areas, and expired food items were found in the refrigerator. The DON and Food Service Director acknowledged routine oversight and training, but the observed practices and expired inventory remained in place.
Two residents with cognitive impairment and complex medical histories experienced pain and swelling that were not promptly assessed or treated according to professional standards. In both cases, staff failed to document comprehensive assessments, did not ensure timely physician notification, and did not carry out or document STAT orders for diagnostic x-rays and pain management. These lapses resulted in delayed diagnoses of fractures and actual harm to at least one resident.
A resident with a history of stroke and dementia experienced increasing pain and swelling in the left arm. Despite a physician's verbal order for a STAT x-ray and Acetaminophen, the order was not entered into the electronic medical record, and there was no documentation that the medication was given or the x-ray performed. Communication failures between nursing staff and lack of documentation led to delayed assessment and intervention, resulting in the resident being transferred to the hospital with a humerus fracture.
A resident with cognitive impairment and medical comorbidities reported being struck on the lip with a bottle by a CNA, resulting in swelling and bruising. The incident was reported to an LPN and assessed by the DON, with the resident consistently identifying the staff member involved. Despite physical findings and staff interviews, the facility's investigation did not substantiate the abuse allegation due to lack of physical evidence and conflicting accounts.
A resident with a history of stroke and dementia experienced new pain and swelling in the left arm, which was reported to nursing staff and led to physician notification, pain medication, and a hospital transfer where a fracture was diagnosed. Despite these significant changes, the care plan was not updated by the interdisciplinary team to reflect the resident's new condition and interventions.
A resident with cognitive impairment and a history of stroke experienced pain and swelling in the left arm, but a nurse did not enter physician orders for pain medication and a STAT x-ray into the EMR due to lack of training. This led to a delay in treatment, with no documentation of medication administration or diagnostic testing, and the resident was later hospitalized with a left arm fracture. Review of records and staff interviews revealed gaps in EMR training and competency verification.
A resident with severe cognitive impairment was physically abused by a CNA during incontinence care, as witnessed by another CNA. The resident, who became restless and reportedly bit the CNA, was slapped several times on the head. Initial assessments found no bruises, but a later examination revealed a bruise under the resident's eye, consistent with the abuse allegation. The facility's investigation confirmed the abuse, despite the resident's medical condition and medication potentially contributing to the bruise.
A resident with dementia and schizophrenia was allegedly slapped by a CNA, but the LTC facility failed to report the incident to authorities within the required two-hour timeframe. The incident was communicated internally, but external reporting was delayed, violating federal and state regulations.
Insufficient Nursing Staffing and Licensed Nurse Coverage
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to provide nursing and related services and failed to have a licensed nurse in charge on each shift. The facility’s Payroll Based Journal Staffing Data Report for the 3rd quarter of Fiscal Year 2025 triggered low weekend staffing, and the facility assessment dated [DATE] listed an average of 310 occupied beds on 8 units with par staffing levels for RNs/LPNs and CNAs by shift and unit. Review of weekend staffing sheets from 04/01/2025 to 06/30/3025 showed multiple shifts without the expected coverage, including a night shift nurse on Unit 4 who called out and was not replaced, an evening shift on Unit 3 with no nurse and the evening supervisor filling in, and a night shift nurse on Unit 6 who was off and not replaced. The staffing sheets also showed that on 06/21/2025 the night shift on Units 6 and 9 had only one CNA each, despite the Physician Order Activity Detail Reports showing that 13 residents on Unit 6 required 2-person physical assist for toilet transfers and 6 required 2 assists for bed mobility, and on Unit 9, 12 residents needed 2-person assist for toilet transfers and 6 needed 2 assists for bed mobility. Additional staffing sheets for 09/01/2025 to 09/07/2025 showed a night shift nurse on Unit 3 who called out and was not replaced, only one CNA on the night shift in Unit 9, an evening nurse on Unit 6 who called out and was not replaced, and a day shift on Unit 6 with no assigned nurse because the assigned nurse was off and the second nurse was floated to another floor for wound treatment. During interviews, a resident stated they required 2 staff to get out of bed and sometimes staff got them out of bed by 2:00 PM, a CNA stated it was sometimes a struggle when there were only 3 CNAs, the Staffing Coordinator stated they were not aware of shifts that did not meet par levels, and the DON stated there were never just one aide to give care on any floor on any shift.
Failure to Notify Resident Representative of Significant Change and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition, specifically when the resident experienced a decline that led to a hospital transfer. The facility's policy required staff to inform both the physician and the resident's designated representative of any significant changes in condition or decisions to transfer. In this case, the resident, who had diagnoses including hypertension, depression, and dementia with moderately impaired cognition, became difficult to arouse and was subsequently transferred to the hospital. Documentation reviewed from the time of the incident did not show that the resident's representative was notified of the change in condition or the hospital transfer. Interviews with facility staff confirmed that the family was only informed after the resident returned from the hospital, at which point the family expressed upset at not being notified earlier. The Assistant Director of Nursing stated that the unit nurse was instructed to contact the family at the time of transfer, but there was no documentation to support that this occurred. The Director of Nursing also acknowledged that immediate notification of family members is required when there is a change in a resident's condition, but confirmed that the family was not informed until after the resident's return.
Failure to Provide Baseline Care Plan Summaries to Residents and Representatives
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to two residents or their representatives within 48 hours of admission, as required by facility policy and regulation. For one resident with diagnoses including heart failure and peripheral vascular disease, there was no documented evidence that the resident received a written summary of the baseline care plan, despite the resident stating they only received a medication list. The baseline care plan was completed, but no documentation showed that the summary was given to the resident or their representative. Similarly, another resident with cerebrovascular accident and heart failure, who had moderately impaired cognition, did not have documented evidence that their representative received the baseline care plan summary. The representative confirmed they had not received the summary. Interviews with facility staff revealed confusion regarding responsibility for providing and documenting the delivery of the baseline care plan summary, with staff members unable to recall issuing the summary or documenting its receipt. The facility's policy requires that the summary be provided in a language understandable to the resident or representative and that receipt be documented, but this was not done for the two residents in question.
Medication doses were omitted and held without proper administration or physician notification
Penalty
Summary
Resident #324, who had diagnoses of glaucoma and hypertension and was documented as cognitively intact, was involved in two medication administration errors identified during survey observation and record review. During medication administration observation, the resident stated they had not been consistently receiving the scheduled 10:00 AM glaucoma eye drops. The physician’s order required Dorzolamide-Timolol eye drops, one drop in each eye twice daily at 10:00 AM and 6:00 PM, but the 10:00 AM dose was not signed off as given. The LPN administering medications stated they became confused by the resident’s questions about the eye drops, did not administer the medication, and then forgot to return to give it after delaying the dose. A second error involved Hydralazine 50 mg ordered three times daily at 10:00 AM, 2:00 PM, and 6:00 PM for hypertension. During observation, an LPN held the 2:00 PM dose because the resident’s blood pressure was 119/53, even though the resident denied complaints or signs or symptoms of hypotension. The dose was not signed off as given, and there was no documented evidence that the physician was notified. The charge nurse stated the LPN should not have omitted the medication without calling the doctor and should have documented the details of the call, and the DON stated that the physician must be called as soon as possible if a medication is held or omitted.
Unlocked Medication Carts Left Unattended
Penalty
Summary
Drugs and biologicals were not stored in accordance with professional standards because medication carts were left unlocked and unattended on two occasions in two different units. The facility policy titled Medication Administration, revised 10/2024, stated that the medication cart should be kept in close view of the nurse at all times and locked unless in use. On 09/16/2025, an LPN left the Unit 3 medication cart unlocked in the hallway while going to Resident #314’s room to administer insulin, and later stated that the cart was forgotten unlocked during the medication pass. On 09/17/2025, an LPN left the Unit 5 medication cart unlocked while going to administer medication to Resident #288, and a medication drawer containing multiple blister packs of pills was observed open in the corridor outside a room and out of view of the nurses’ station. The LPN stated it was unsafe to leave the cart unlocked with the drawers open because someone could take medications without the nurse’s knowledge. The DON stated that nurses should lock medication carts when leaving them in the hallway to administer medication and that leaving carts open, unlocked, and unattended is a safety issue.
Food Safety and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards of food service safety. During a dining observation in Unit 9, a CNA brought Resident #183’s lunch tray to the room, moved items on the bedside table, picked up a remote control after it fell on the floor, and then opened a soda can and a sandwich with bare hands without performing hand hygiene. The CNA then assisted Resident #122 with an electronic device and placed Resident #173’s lunch tray on the table, again without performing hand hygiene. When interviewed, the CNA stated they were moving fast and only realized hand hygiene had not been performed when asked by the State Surveyor. The facility also failed to follow its facial hair restraint policy in the kitchen and tray line areas. The Food Service Manager was observed in the kitchen with visible mustache, beard, and sideburns without a beard guard, and another staff member was later observed in the tray line area with a mustache not properly covered. In addition, expired food items were found in the refrigerator, including potato salad past its best-if-used-by date and skinless boneless turkey breast past its use-or-freeze-by date. The DON and Food Service Director stated they conduct inspections and training, but the expired items were still present during observation.
Failure to Provide Timely Assessment and Care for Pain and Injury
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the person-centered care plan, and resident preferences for two of seven sampled residents. In the first case, a resident with a history of cerebrovascular accident, hemiplegia, and dementia complained of left arm pain over multiple days. Despite these complaints, there was no documented evidence that a pain assessment was conducted, pain medication was administered, or that a physician was notified in a timely manner. Orders for a STAT x-ray and acetaminophen were reportedly given verbally but were not entered into the electronic medical record, nor was there evidence that these orders were communicated to the appropriate staff or carried out. The resident's condition worsened, with increased swelling and altered mental status, leading to a hospital transfer where a left proximal humerus fracture was diagnosed. Documentation gaps and communication failures among nursing staff and between nursing and medical staff contributed to the lack of timely intervention and treatment for the resident's pain and swelling. In the second case, another resident with severe cognitive impairment and multiple comorbidities complained of left leg and hip pain. The initial response involved administration of Tylenol, but there was no comprehensive assessment or timely notification of a physician on the day the pain was first reported. Subsequent documentation showed that swelling and limited range of motion were observed, and a STAT x-ray was ordered only after further assessment the following day. However, the x-ray was not performed in the facility, and the resident was eventually transferred to the hospital, where a displaced comminuted intertrochanteric fracture of the left proximal femur was diagnosed. There was no evidence that a thorough physical assessment was documented at the time of the initial complaint, nor that the physician was notified promptly. Delays in diagnostic testing and incomplete documentation contributed to the deficiency. Both cases demonstrate failures in following facility policies regarding pain assessment, change in condition, and timely execution of physician orders for diagnostic services. There were repeated lapses in communication, documentation, and follow-through on physician orders, resulting in residents not receiving appropriate and timely care for their complaints of pain and changes in condition. These deficiencies led to actual harm for at least one resident, as evidenced by the delayed diagnosis and treatment of a fracture.
Failure to Provide Timely and Appropriate Pain Management and Documentation
Penalty
Summary
A resident with a history of cerebrovascular accident with hemiplegia and dementia, whose primary language is Creole, reported pain in the left arm. Initial assessment by nursing staff resulted in the administration of Acetaminophen, which provided only temporary relief. Over the following days, the resident exhibited increasing swelling and pain in the left upper arm, which was observed by both nursing staff and a certified nursing assistant. Despite these ongoing symptoms, there was a lack of consistent documentation and follow-up regarding the resident's pain and swelling. A physician was notified and gave a verbal order for a STAT x-ray and Acetaminophen 1000 mg. However, the order was not entered into the electronic medical record, and there was no documented evidence that the medication was administered or that the x-ray was performed. Communication breakdowns occurred between shifts, with staff failing to relay critical information about the resident's condition and physician orders. The resident's pain management care plan was not updated to reflect the new symptoms or interventions, and the resident was not placed on the 24-hour report as required by facility policy. The resident's condition deteriorated, with increased swelling, warmth in the affected area, and altered mental status. Eventually, the resident was transferred to the hospital, where a left proximal humerus fracture was diagnosed. Interviews with staff revealed confusion and lack of clarity regarding the handling of physician orders, documentation, and follow-up care. There was no evidence of abuse, neglect, or staff misconduct related to the fracture, but the facility failed to provide safe, appropriate pain management and did not follow its own policies for assessment, documentation, and communication.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and a history of hypertension and anxiety disorder reported being struck on the upper lip with a bottle by a certified nursing assistant. The incident was initially reported to an LPN, who observed slight swelling to the resident's upper lip. The DON assessed the resident and confirmed the swelling, but no bruising or bleeding was noted at that time. The resident consistently identified the same staff member as the alleged perpetrator, and multiple staff interviews confirmed the resident's report of being hit with a bottle, although the specific bottle was not located in the room. The facility's investigation included interviews with the alleged staff member, who denied the incident, and other staff who responded to the resident's call bell. One CNA reported that the accused CNA admitted to throwing a bottle at the resident after being hit, but this was not corroborated by physical evidence. The resident was placed on frequent monitoring and referred for psychiatric and psychological evaluation. Subsequent medical assessment documented increased swelling and bruising to the resident's lips, including new areas of discoloration inside the mouth. Despite the resident's consistent statements and physical findings, the facility concluded there was no evidence of abuse, neglect, or mistreatment, citing the absence of the bottle and conflicting staff accounts. The investigation did not substantiate the resident's allegation, and the accused staff member was removed from the schedule but did not return to the facility. The deficiency centers on the facility's failure to ensure the resident was free from abuse, as required by policy and regulation.
Failure to Update Care Plan After Resident's Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's care plan was reviewed and revised by the interdisciplinary team following a significant change in the resident's condition. The resident, who had a history of cerebrovascular accident with hemiplegia and dementia, reported pain in the left arm to a CNA, which was communicated to an RN. The following day, the resident again complained of pain, and swelling was observed in the left arm. The RN notified the physician, who ordered Tylenol and a STAT x-ray. The resident was subsequently transferred to the hospital with altered mental status, elevated blood pressure, and was later diagnosed with a fracture of the left proximal humerus. Despite these significant changes in the resident's condition, including new pain, swelling, and a hospital transfer for further evaluation, there was no documented evidence that the care plan was updated to reflect these developments. The existing pain management care plan had last been updated months prior and indicated the resident was stable with no complaints of pain. Interviews with facility staff confirmed that care plans are expected to be updated with changes in condition, but in this case, the care plan was not revised to address the resident's new symptoms and interventions.
Failure to Ensure Nurse Competency in EMR Use Delays Resident Treatment
Penalty
Summary
A deficiency occurred when a registered nurse failed to enter physician orders for pain medication and a STAT x-ray into the facility's electronic medical record (EMR) after a resident complained of left arm pain and swelling. The nurse stated they did not receive adequate training on the EMR system (Sigma) and therefore did not transcribe the orders, instead verbally notifying the oncoming LPN to have the supervisor enter the orders. As a result, there was no documented evidence that the ordered Tylenol or x-ray were provided, leading to a delay in treatment. The resident involved had a history of cerebrovascular accident with hemiplegia and dementia, and was noted to have mentally impaired cognition. The resident's condition worsened, with increased swelling of the left arm, elevated blood pressure, and altered mental status, eventually requiring transfer to the hospital where a left arm fracture was diagnosed. Review of facility records confirmed the absence of documentation for the physician's orders and administration of medication, as well as a lack of evidence that the nurse had completed EMR training per facility policy. Interviews with the nurse, facility educator, and DON revealed inconsistencies in the orientation and competency verification process for EMR use. The nurse reported insufficient training and lack of familiarity with required documentation procedures, while the educator and DON described a structured orientation and competency sign-off process. However, the staff development checklist for the nurse did not show documented evidence of EMR training, and the nurse stated they had not signed any checklist for Sigma training.
Resident Abuse by CNA During Care
Penalty
Summary
The facility failed to protect a resident from physical abuse by nursing home staff, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who was witnessed slapping a resident during incontinence care. The incident occurred when two CNAs were providing care to a resident with severe cognitive impairment due to Non-Alzheimer's Dementia and Paranoid Schizophrenia. The resident became restless and reportedly bit one of the CNAs, who then retaliated by slapping the resident several times on the head. Initially, a physical assessment by a Registered Nurse found no bruises, but a subsequent assessment by the Director of Nursing revealed a red bruise under the resident's left eye, consistent with the reported abuse. The facility's policy on abuse and neglect emphasizes the protection of residents from abuse by anyone, including staff. Despite this policy, the incident was reported by one CNA to a Licensed Practical Nurse, who then informed the Registered Nurse Supervisor. The facility's investigation confirmed the occurrence of abuse, as both CNAs admitted that the resident had no head or facial discoloration prior to the care. The resident's medical condition, including the use of blood thinners, was noted by a Medical Doctor as a possible factor for the bruise, but the facility concluded that the abuse occurred as alleged.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner as required by federal and state regulations. On the evening of April 19, 2024, a Certified Nursing Assistant (CNA) reported to a Licensed Practical Nurse (LPN) that another CNA had slapped a resident several times on the head. The incident was communicated to the Director of Nursing (DON) and the facility's Administrator later that night. However, the facility did not report the allegation to law enforcement and the New York State Department of Health within the mandated two-hour timeframe. The facility's policy requires immediate reporting of such incidents, defined as within two hours if the event involves abuse or results in serious bodily injury. The resident involved had a history of Non-Alzheimer's Dementia and Paranoid Schizophrenia, with severely impaired cognition as indicated by a recent assessment. Initially, no visible injuries were noted, but a subsequent examination revealed a bruise under the resident's left eye, consistent with the abuse allegation. The facility's failure to report the incident promptly was a violation of their own policy and regulatory requirements, as the incident was not reported to the appropriate authorities until several hours after it was first discovered.
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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.
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Nursing homes near New York
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Henry J. Carter Skilled Nursing Facility | 0.1 mi | ★★★★★ | 2 | 1 |
| Harlem Center For Nursing And Rehabilitation, L L | 0.7 mi | ★★★★★ | 3 | 0 |
| Terence Cardinal Cooke Health Care Center | 1 mi | ★★★★★ | 0 | 0 |
| St Marys Center Inc | 1.1 mi | ★★★★★ | 0 | 0 |
| Amsterdam Nursing Home Corp (1992) | 1.3 mi | ★★★★★ | 0 | 0 |
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