Manhattan Community Care Center

In the surveyor’s words

From the most serious findings on record at Manhattan Community Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 18, 2025

  Based on observation, interviews, record review and facility policy review, the facility failed to provide adequate supervision and a secure environment to prevent the elopement of one (1) of six (6) sampled residents, Resident #9.On 9/08/25 a newly admitted respite resident with diagnoses of restlessness and agitation, dementia and senile degeneration of brain and history of exit seeking behaviors and falls was assisted to exit the facility by staff, was outside unsupervised for twenty-five (25) minutes until a staff member observed the resident lying on the ground next to the iron fence that encircled the facility premises, approximately three hundred seventy-five (375) feet from the facility entrance.The facility's failure to provide adequate supervision to prevent the elopement of… […]

• Immediate jeopardy, isolatedF656Nov 5, 2021

  Based on record review, facility policy review, and staff interview, the facility failed to develop a comprehensive care plan which provided sufficient water intake to provide adequate hydration for one (1) of (16) residents who require enteral feedings. Resident #2 On 9/04/21 the Registered Dietician (RD) #1 reviewed nutrition and hydration requirements for Resident #2 and made a recommendation to change the tube feeding orders for Resident #2. The Physician (MD #1) reviewed the recommendations and approved them and issued physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore, the Care Plan was not developed to provide adequate hydration for Resident #2. […]

• Immediate jeopardy, isolatedF692Nov 5, 2021

  Based on record review, facility policy review, and staff interview the facility failed to ensure Resident #2 received free water flushes through his Percutaneous Endoscopic Gastrostomy (PEG) tube to maintain adequate hydration status which resulted in Resident #2 becoming Hypovolemic (Dehydrated), resulting in Resident #2 being transferred to the local hospital and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2. On 9/04/21 the Registered Dietician (RD #1) reviewed nutrition and hydration requirements for Resident #2 and made a recommendation to change the tube feeding orders for Resident #2 which included 175 milliliter free water flushes every four (4) hours. […]

• Immediate jeopardy, isolatedF693Nov 5, 2021

  Based on record review, facility policy review, and staff interview the facility failed to ensure Resident #2 received free water flushes through his Percutaneous Endoscopic Gastrostomy (PEG) tube to maintain adequate hydration status which resulted in Resident #2 becoming Hypovolemic (Dehydrated), resulting in Resident #2 being transferred to the local hospital and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .Resident #2. On 9/04/21 the Registered Dietician (RD #1) reviewed nutrition and hydration requirements for Resident #2 and made a recommendation to change the tube feeding orders for Resident #2 which included 175 milliliter free water flushes every four (4) hours. […]

• Actual harm, isolatedF656Feb 27, 2025

  Based on staff interview, record review, and facility policy review, the facility failed to implement a care plan intervention regarding one-on-one supervision for a severely cognitive impaired resident which resulted in an unsupervised fall, leading to an acute transverse fracture of the lower sacrum for one (1) of two (2) care plans reviewed for falls. Resident #1 Findings Include: A review of the facility's policy, Resident [NAME] of Rights, revised January 2023, revealed: Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life . A. […]