Mary Manning Walsh Nursing Home Co Inc

Based on observations, record review, and interviews conducted during an abbreviated survey (2648284), the facility did not ensure a resident's physician was notified of changes in condition. This was evident for one (1) of four (4) residents (Resident #1) sampled. Specifically, on 10/18/2025 at 9:30 AM, Resident #1, who required supervision with ambulation, spilled hot coffee on their right hand while they were ambulating in the hallway holding onto their rolling walker with their left hand, and holding a cup of hot coffee in their right hand. A physician or nursing supervisor was not immediately notified of the changes in Resident #1's condition. Physician #1 became aware of the burn on 10/20/2025 and assessed Resident #1 to have sustained a third-degree burn to their right hand and thumb. Cold compress and Bacitracin Ointment treatment was applied and burn area was covered with dry gauze. The findings include:A policy titled 'Notification of Resident's Change in Condition'' dated 04/2025 documented that it is the responsibility of the Licensed Nurse/Designee to assess the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews conducted during an abbreviated survey (2648284), the facility failed to ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for one (1) of four (4) residents (Resident #1) sampled. Specifically, Resident #1 spilled hot coffee on their right hand on 10/18/2025 at 9:30 AM. Registered Nurse #1 who was notified by Certified Nursing Assistant #1 on 10/18/2025 at 9:30 AM, did not notify the administrator or designee within…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews conducted during an abbreviated survey (2648284), the facility failed to provide an environment that is free from accident hazards and to ensure that a resident received adequate supervision to prevent accidents. This was evident for one (1) of four (4) residents (Resident #1) sampled. Specifically, on 10/18/2025 at 9:30 AM, Resident #1, who required supervision with ambulation, spilled hot coffee on their right hand while they were ambulating in the hallway holding onto their rolling walker with their left hand, and holding a cup of hot coffee in their right hand Resident #1 was assessed on 10/20/2025 by Physician #1 and was diagnosed with a third-degree burn to their right hand and thumb. Cold compress and Bacitracin Ointment treatment was applied and burn area was covered with dry gauze. The findings include:A policy titled 'Microwave Use-Reheating Foods or Liquids in the Microwave' dated 02/2023 documented it is the facility's policy to provide food and hot liquids at comfortable and safe temperatures, ensure that resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews, the facility failed to provide necessary services to maintain good grooming and personal hygiene to a resident who is unable to carry out activities of daily living. This was evident for one (1) (Resident #280) of three (3) residents reviewed for Choices out of 33 total sampled residents. Specifically, Resident #280 was not provided showers as stated in the care plan. The findings include:The facility's policy titled Activities of Daily Living Support with a last reviewed date of 03/2025 documented that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy's interpretation and implementation documented that appropriate care, and services will be provided for residents who are unable to carry out activities of daily living independently,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interviews, the facility failed to ensure each resident received food that accommodated their preferences. This was evident for one (1) (Resident #404) of three (3) residents reviewed for Choices out of 35 total sampled residents. Specifically, Resident #404, who's meal preferences include salad for lunch and dinner, are often not being met. The findings include:The facility policy titled Meal/Tray Assembly Procedures with a last revised date of 01/2025 documented that meal service is prompt and accurate to ensure temperatures and nutrient content of food is preserved. The procedure included to check meals for accuracy.Resident #404 had diagnoses of Diabetes Mellitus and Hypertensive Heart Disease.A dietary progress notes dated 08/06/2025 at 1:46 PM documented that Resident #404 preferred vegetables.The dietary order dated 08/31/2025 documented that Resident #404 requested additional salad for lunch and supper. A comprehensive care plan for nutrition concerns was initiated for Resident #404 on 08/08/2025. The care plan interventions included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification and Complaint (NY00324925) survey from 11/09/2023 to 11/16/2023, the facility did not ensure all alleged violations involving abuse were reported within 2 hours to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident #14) of 40 total sampled residents. Specifically, Resident #14 reported an allegation of abuse that was not reported to the NYSDOH within 2 hours of occurrence. The findings are: The facility's policy titled Abuse Prevention Policy and Procedure dated 10/3/2022 documented all alleged violations must be reported immediately but no later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. Resident #14 had diagnoses of major depressive disorder and anxiety disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #14 was moderately cognitively impaired and required the assistance of 1-2 people to complete activities of daily living.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews conducted during the Recertification and Abbreviated survey (NY00321684), the facility did not ensure that a resident received adequate supervision to prevent elopement. This was evident for 1 of 5 residents reviewed for Accidents (Resident #375) out of a sample of 38 residents. Specifically, on 8/8/23, Resident #375, identified as a high risk for elopement and wearing a wander guard, took the elevator from the 9th floor and exited the building through the front door. The findings include: The facility's policy and procedure titled Elopement, with the last revised date of June 2021 documented that the facility's purpose is to ensure that all residents identified as at risk for elopement/unsafe wandering do not elope from the facility. The policy further states that elopement occurs when a resident leaves the premises or safe area without authorization and any necessary supervision. Resident #375 was admitted with diagnoses that include Malignant Neoplasm of the Brain and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon observation and interview, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food safety. Specifically, staff were observed not performing hand hygiene in between tasks and food handling. This was evident for the Kitchen Observation facility task. The findings are: Specifically, Policy and Procedure titled Sanitation and Infection Prevention/Control Subject Hand Hygiene, date issued: 5/95, revised 1/22, documented in the Food & Nutrition Services Department, all associates associated with the handling of food shall wash hands. Hands are washed with soap and water at the following times: before handling food or clean utensils/dishes/equipment, before putting on gloves, and after any other activity that may contaminate the hands. On 01/11/22 at 11:46 AM, the Second [NAME] was observed coming out of the walk-in refrigerator with gloves on. The Second [NAME] left the kitchen, walked across the hall to the dry storage area, and exited the storage area still wearing the same gloves. The Second [NAME] returned…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews conducted during the Recertification survey, the facility failed to notify a resident's medical provider when there was a need to alter treatment significantly. Specifically, a resident's medical provider was not informed when the resident's blood sugar increased to 350 on one occasion. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a sample of 35 (Resident #245). The finding is: The Facility's policy titled Clinical, Acute change in condition, System -Wide last revised 8/27/18 documented it is the policy of the facility that acute changes in resident's condition are immediately shared with the resident/representative and reported to the attending physician. The nurse should immediately notify the resident's physician and the resident/ resident representative of acute changes due to abnormal vital signs, blood glucose levels that are beyond MD parameters, abnormal lab results and abnormal X-ray results. Resident # 245 was admitted with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews conducted during recertification and complaint (NY00272048) survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed to address resident's concerns. Specifically, there was no documented evidence that a comprehensive care plan was developed and implemented with appropriate interventions to address resident #326 actual fall and resident # 574 use of oxygen therapy. This was evident for 2 of 38 sampled residents (Resident #326 & Resident #574). The finding is: 1) Resident #326 was originally admitted to the facility on [DATE] with diagnoses of BPH, ESRD, pneumonia, hyperlipidemia, arthritis, and asthma. The admission MDS dated [DATE] documented the that the resident cognitive level is intact. The resident requires extensive assistance and two persons assist for bed mobility, transfer and toileting. The MDS documented no falls. Nursing note dated 2/20/21 documented the resident was found on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during Re-certification Survey from 1/6/2022 to 1/13/2022, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, a resident received oxygen therapy without a physician's order for one month, and there was no care plan in place for oxygen therapy. This was evident for 1 out of 4 residents reviewed for Quality of Care out of a sample of 38 residents (Resident # 574). The findings are: The facility policy and procedure titled Comprehensive Care Plan dated 9/07 and last revised 11/2021 documented the Comprehensive Care Plan (CCP) is developed by the Interdisciplinary Team within 7 days after completion of the comprehensive assessment. It also documented the Interdisciplinary Team shall include Licensed Nurse with responsibility for the Resident, Dietician, Social Worker, CNA, Activity Worker, Therapist if applicable. The facility policy and procedure titled Oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview conducted during the Recertification survey, the facility did not ensure that medication and biologicals were labeled in accordance with currently accepted professional principles, and include the appropriate expiration date when applicable. Specifically, eye drops, insulin vials, and insulin pens did not have labels that included the medication name, prescribed dose, strength, expiration date, the resident's name, route of administration, and appropriate instructions and precautions directly affixed to the medication. The medication labels were affixed to plastic bags. This was evident 1 on 11 units reviewed for Medication Storage (Unit 9). The findings are: The Medication Storage Policy was requested. On [DATE] at 11:13 AM, an observation of the medication cart on the 9th floor was conducted during Medication Storage Observation with the Registered Nurse (RN# 6). One unlabeled open bottle of cyclopentolate hydrochloride ophthalmic solution 2% was in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.