Inspection Reports for
Delmar Center for Rehabilitation and Nursing
125 Rockefeller Road, Delmar, NY, 12054
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Inspection Report — Mar 6, 2026
State
Date: Mar 6, 2026
Visit Reason
State-compiled facility profile showing 18 inspections from 2022 to 2026 with detailed deficiency and enforcement history.
Complaint Details
The state logged 209 complaints about this facility; 20 led to on-site inspections.
Findings
Across 18 inspections, 12 had no citations while 6 resulted in 166 citations primarily related to standard health and Life Safety Code issues. The facility had 209 complaints with 20 on-site inspections and 3 enforcement actions totaling $20,000 in fines.
Citations (64)
Standard Health Citation — quality of care: Activities Meet Interest/needs Each Resident was deficient.
Standard Health Citation — quality of care: ADL Care Provided For Dependent Residents was deficient.
Standard Health Citation — quality of care: Competent Nursing Staff was deficient.
Standard Health Citation — quality of care: Develop/implement Comprehensive Care Plan was deficient.
Standard Health Citation — quality of care: Drug Regimen Is Free From Unnecessary Drugs was deficient.
Standard Health Citation — quality of care: Infection Prevention & Control was deficient.
Standard Health Citation — quality of care: Label/store Drugs And Biologicals was deficient.
Standard Health Citation — quality of care: Resident Rights/exercise Of Rights was deficient.
Standard Health Citation — quality of care: Respiratory/tracheostomy Care And Suctioning was deficient.
Standard Health Citation — quality of care: Right To Be Free From Chemical Restraints was deficient.
Life Safety Code Citation — NFPA requirements: Cooking Facilities were deficient.
Life Safety Code Citation — NFPA requirements: Corridor - Doors were deficient.
Life Safety Code Citation — NFPA requirements: Electrical Equipment - Power Cords And Extens were deficient.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric Syste were deficient.
Life Safety Code Citation — NFPA requirements: Portable Fire Extinguishers were deficient.
Life Safety Code Citation — NFPA requirements: Portable Space Heaters were deficient.
Life Safety Code Citation — NFPA requirements: Utilities - Gas And Electric were deficient.
Standard Health Citation — quality of care: Administration was deficient.
Standard Health Citation — quality of care: Care Plan Timing And Revision was deficient.
Standard Health Citation — quality of care: Dispose Garbage And Refuse Properly was deficient.
Standard Health Citation — quality of care: Food Procurement,store/prepare/serve-sanitary was deficient.
Standard Health Citation — quality of care: Free From Abuse And Neglect was deficient.
Standard Health Citation — quality of care: Free Of Accident Hazards/supervision/devices was deficient.
Standard Health Citation — quality of care: Free Of Medication Error Rts 5 Prcnt Or More was deficient.
Standard Health Citation — quality of care: Grievances was deficient.
Standard Health Citation — quality of care: Infection Preventionist Qualifications/role was deficient.
Standard Health Citation — quality of care: Investigate/prevent/correct Alleged Violation was deficient.
Standard Health Citation — quality of care: Notice Of Bed Hold Policy Before/upon Trnsfr was deficient.
Standard Health Citation — quality of care: Nutrition/hydration Status Maintenance was deficient.
Standard Health Citation — quality of care: Pasarr Screening For Md & Id was deficient.
Standard Health Citation — quality of care: Personal Food Policy was deficient.
Standard Health Citation — quality of care: Qaa Committee was deficient.
Standard Health Citation — quality of care: Quality Of Care was deficient.
Standard Health Citation — quality of care: Reporting Of Alleged Violations was deficient.
Standard Health Citation — quality of care: Resident Records - Identifiable Information was deficient.
Standard Health Citation — quality of care: Resident Self-admin Meds-clinically Approp was deficient.
Standard Health Citation — quality of care: Residents Are Free Of Significant Med Errors was deficient.
Standard Health Citation — quality of care: Responsibilities Of Providers; Required Notif was deficient.
Standard Health Citation — quality of care: Right To Survey Results/advocate Agency Info was deficient.
Standard Health Citation — quality of care: Rn 8 Hrs/7 Days/wk, Full Time Don was deficient.
Standard Health Citation — quality of care: Safe/clean/comfortable/homelike Environment was deficient.
Standard Health Citation — quality of care: Sufficient Nursing Staff was deficient.
Standard Health Citation — quality of care: Transfer And Discharge Requirements was deficient.
Life Safety Code Citation — NFPA requirements: Discharge From Exits was deficient.
Life Safety Code Citation — NFPA requirements: Doors With Self-closing Devices was deficient.
Life Safety Code Citation — NFPA requirements: Ep Testing Requirements was deficient.
Life Safety Code Citation — NFPA requirements: Ep Training Program was deficient.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance was deficient.
Life Safety Code Citation — NFPA requirements: Horizontal Exits was deficient.
Life Safety Code Citation — NFPA requirements: Illumination Of Means Of Egress was deficient.
Life Safety Code Citation — NFPA requirements: Maintenance, Inspection & Testing - Doors was deficient.
Life Safety Code Citation — NFPA requirements: Means Of Egress - General was deficient.
Life Safety Code Citation — NFPA requirements: Organization And Administration was deficient.
Life Safety Code Citation — NFPA requirements: Plan Based On All Hazards Risk Assessment was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Installation was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing was deficient.
Standard Health Citation — quality of care: Lab Srvcs Physician Order/notify Of Results was deficient.
Standard Health Citation — quality of care: Laboratory Services was deficient.
Standard Health Citation — quality of care: Routine/emergency Dental Srvcs In Snfs was deficient.
Standard Health Citation — quality of care: Training Requirements was deficient.
Life Safety Code Citation — NFPA requirements: Multiple Occupancies was deficient.
Standard Health Citation — quality of care: Facility Assessment was deficient.
Standard Health Citation — quality of care: Treatment/svcs To Prevent/heal Pressure Ulcer was deficient.
Standard Health Citation — quality of care: Respiratory/tracheostomy Care And Suctioning was deficient.
Report Facts
Inspections on page: 18
Total violations/deficiencies cited: 166
Inspections with violations: 6
Inspections without violations: 12
Total complaints: 209
On-site inspections from complaints: 20
Citations issued from complaints: 36
Enforcement actions: 3
Total fines: 20000
Inspection Report — Jan 23, 2025
Annual Inspection CMS
Date: Jan 23, 2025
Visit Reason
Annual recertification survey and abbreviated survey to assess compliance with state and federal regulations for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including resident dignity, medication management, infection control, staffing, care planning, nutrition, respiratory care, and environmental safety. Significant issues included failure to provide adequate staffing, improper medication administration, inadequate infection prevention practices, and insufficient resident care planning and activities.
Citations (31)
F550: The facility failed to ensure residents were treated with dignity and respect, including accommodating resident needs and privacy.
F554: The facility did not assess residents for ability to safely self-administer medications and lacked physician orders for self-administration.
F577: Survey results were not posted in a location accessible to residents, visitors, or staff, limiting transparency.
F584: The facility environment was not maintained in a safe, clean, and homelike manner, with issues in housekeeping and maintenance.
F585: Residents were not provided with adequate means to file grievances anonymously and without fear of reprisal.
F600: The facility failed to protect residents from abuse and neglect, including a fall resulting in a broken leg due to care plan violation.
F609: The facility failed to timely report incidents of abuse and neglect to the State Survey Agency as required.
F622: The facility did not ensure residents had safe and appropriate discharge planning and education, including appeal rights.
F625: The facility failed to provide written notice of bed-hold policy to residents and representatives upon hospital transfer.
F645: The facility did not complete required preadmission screening and resident review (PASARR) for mental illness or intellectual disabilities for multiple residents.
F656: The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives for multiple residents' diagnoses and needs.
F657: The facility failed to review and revise comprehensive care plans based on changing resident needs and conditions.
F679: The facility failed to provide activities that met residents' interests and supported their physical, mental, and psychosocial well-being.
F684: The facility failed to provide services consistent with professional standards of practice, including medication administration and care.
F689: The facility failed to maintain a safe environment free from accident hazards and provide adequate supervision to prevent accidents.
F692: The facility failed to maintain acceptable nutritional status and hydration for residents, including monitoring weights and providing ordered fluids.
F695: The facility failed to provide respiratory care consistent with physician orders and professional standards, including oxygen therapy monitoring.
F725: The facility failed to provide sufficient nursing staff to meet resident care needs and comply with minimum staffing requirements.
F726: The facility failed to ensure nursing staff were competent and oriented to provide safe care.
F727: The facility failed to provide a registered nurse on duty for at least 8 consecutive hours per day, 7 days a week.
F757: The facility failed to ensure residents' drug regimens were free from unnecessary medications and included indications for use.
F759: The facility's medication error rate exceeded 5%, including crushing medications not ordered to be crushed.
F760: The facility failed to ensure residents were free from significant medication errors, including improper medication timing.
F761: The facility failed to store drugs and biologicals properly, including unlabeled opened medications and unsecured narcotics.
F812: The facility failed to maintain food service areas in a clean and sanitary condition, including kitchen equipment and nutrition rooms.
F813: The facility failed to ensure safe storage and handling of foods brought in by families and visitors, including unlabeled and unmonitored food.
F814: The facility failed to properly dispose of garbage and refuse, including unsecured dumpsters and litter around the area.
F842: The facility failed to maintain complete, accurate, and accessible medical records, including incomplete treatment documentation.
F868: The facility failed to maintain a quality assurance program with required members and regular meetings.
F880: The facility failed to implement infection prevention and control practices consistent with professional standards, including PPE use and catheter care.
F882: The facility failed to designate a qualified Infection Preventionist responsible for infection control program oversight.
Report Facts
Medication error rate: 22.22
Licensed nurse staffing hours: 120
Certified nurse aide staffing hours: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deprincess Golden | Staffing Coordinator | Discussed staffing schedules and recruitment |
| Director of Nursing #1 | Director of Nursing | Provided multiple interviews regarding staffing, infection control, medication administration |
| Administrator #1 | Administrator | Provided interviews regarding staffing, quality assurance, grievance process |
| Registered Nurse #1 | Registered Nurse | Interviewed about medication administration and care planning |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed about medication administration and staffing |
| Dietitian #1 | Dietitian | Interviewed about nutritional monitoring and weight management |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed about hydration and infection control practices |
Inspection Report — May 23, 2024
Abbreviated Survey CMS
Date: May 23, 2024
Visit Reason
The survey was conducted as an abbreviated survey to investigate allegations of abuse, medication errors, laboratory service delays, and other compliance concerns at the nursing facility.
Complaint Details
The survey was complaint and allegation driven, investigating verbal and physical abuse allegations involving Residents #1 and #3, medication administration concerns for Resident #1, delayed laboratory testing and notification for Resident #2, and medication storage issues for Resident #3.
Findings
The facility was found to have multiple deficiencies including verbal abuse of a resident by staff, failure to timely report and investigate abuse allegations, inadequate treatment and monitoring of a resident's injury, medication administration errors including hoarding and improper timing, unsecured medications accessible to residents, delayed laboratory testing and failure to notify providers of abnormal results, and incomplete medical record documentation.
Citations (9)
F0550: The facility failed to ensure Resident #1 was treated with respect and dignity during a verbal altercation with staff on 1/12/2024, including use of racial slurs by Certified Nurse Aide #1.
F0609: The facility failed to timely report allegations of abuse involving Residents #1 and #3 to the Administrator and State Agency, and did not thoroughly investigate these allegations promptly.
F0684: The facility failed to provide appropriate treatment and care for Resident #3 by not documenting or monitoring a scratch injury from 1/10/2024 through 1/24/2024, and delayed identification of the injury until survey time.
F0689: The facility failed to ensure Resident #3's medications were stored securely when a bottle of aspirin was found unsecured on the resident's nightstand.
F0760: The facility failed to ensure Resident #1 received prescribed Oxycodone on 1/21/2024 as ordered, administering doses too close together and late.
F0761: The facility failed to ensure all drugs were stored in locked compartments as a bottle of aspirin was found unsecured in Resident #3's room.
F0770: The facility failed to provide timely laboratory services for Resident #2, with a CBC test ordered for 12/25/2023 not completed until 12/29/2023, and failure to notify the provider of abnormal results promptly.
F0773: The facility failed to promptly notify the ordering practitioner of abnormal laboratory results for Resident #2 on 12/29/2023, with notification delayed until 1/2/2024.
F0842: The facility failed to maintain complete, accurate, and timely medical records for Resident #2, lacking documentation of assessments, physician notifications, orders, and resident responses related to a change in condition from 12/31/2023 to 1/1/2024.
Report Facts
Oxycodone pills found: 10
Oxycodone dose time delay: 3
Scratch size: 5
CBC hemoglobin level: 7.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named in verbal abuse incident with Resident #1. | |
| Certified Nurse Aide #1 | Named in verbal abuse incident with Resident #1. | |
| Certified Nurse Aide #4 | Involved in verbal altercation with Resident #1. | |
| Licensed Practical Nurse Supervisor #5 | Witnessed verbal altercation and failed to timely report abuse. | |
| Director of Nursing #1 | Director of Nursing | Involved in investigation and interviews related to abuse and medication errors. |
| Administrator #1 | Administrator | Involved in investigation and interviews related to abuse and medication errors. |
| Physician Assistant #1 | Physician Assistant | Ordered labs and involved in pain management for Resident #1 and #2. |
| Licensed Practical Nurse #3 | Responsible for medication pass and medication storage issues. | |
| Licensed Practical Nurse #7 | Administered Oxycodone doses late to Resident #1. | |
| Registered Nurse Supervisor #1 | Involved in investigation of abuse and lab testing delays. | |
| Licensed Practical Nurse Manager #4 | Involved in skin monitoring and wound assessment for Resident #3. |
Inspection Report — Nov 30, 2023
Abbreviated Survey CMS
Date: Nov 30, 2023
Visit Reason
The facility underwent an abbreviated survey to assess compliance with regulatory requirements including environmental safety, care planning, activities of daily living, pressure ulcer care, dental services, food safety, facility assessment, and infection control.
Findings
The survey found multiple deficiencies including unsanitary resident rooms and bathrooms, incomplete and inadequate care plans, insufficient assistance with activities of daily living, failure to prevent and properly monitor pressure ulcers, failure to replace lost dentures, food service safety violations, incomplete facility assessment regarding bariatric care, and inadequate infection prevention and control practices.
Citations (8)
F 0584: The facility did not ensure a safe, clean, and homelike environment; resident rooms and bathrooms were dirty, had holes in walls, and were in disrepair.
F 0656: The facility did not develop and implement a comprehensive, person-centered care plan with measurable objectives for one resident, omitting support for activities of daily living and skin care.
F 0677: The facility failed to provide necessary assistance with activities of daily living for three residents, including improper disposal of soiled briefs, inadequate denture care, and failure to provide scheduled showers due to lack of bariatric equipment.
F 0686: The facility did not provide appropriate pressure ulcer care for one resident who developed a pressure ulcer after admission and failed to conduct weekly wound assessments and documentation.
F 0790: The facility did not ensure replacement of a lost denture for one resident and failed to reimburse the resident for the cost of replacement.
F 0812: The facility did not store, prepare, distribute, or serve food in accordance with professional standards; issues included excessive dishwashing machine water pressure, unclean kitchen areas, peeling walls, and leaking faucet.
F 0838: The facility assessment did not address care and equipment needs for bariatric residents, omitting necessary resources such as bariatric beds and mechanical lifts.
F 0880: The facility failed to maintain an infection prevention and control program; resident dentures and toothbrushes were not stored or discarded properly, and resident bathrooms were not cleaned and sanitized adequately.
Report Facts
Bariatric residents: 14
Mechanical lifts: 3
Dishwashing machine water pressure: 60
Cost of denture replacement: 4500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plans, wound care, shower scheduling, infection control, and facility assessment | |
| Director of Housekeeping | Interviewed regarding cleaning expectations and audits | |
| Assistant Director of Nursing | Interviewed regarding wound care and denture care | |
| Food Service Director | Interviewed regarding kitchen cleanliness and dishwashing machine issues | |
| Licensed Practical Nurse #6 | Interviewed regarding denture loss and nursing responsibilities | |
| Social Worker #1 | Interviewed regarding denture replacement coordination | |
| Medical Records Associate #1 | Interviewed regarding dental appointments for denture replacement | |
| Certified Nurse Aide #5 | Interviewed regarding incontinence care and denture cleaning | |
| Certified Nurse Aide #3 | Interviewed regarding shower assistance and equipment availability | |
| Certified Nurse Aide #7 | Interviewed regarding bariatric sling availability |
Inspection Report — Feb 3, 2023
Annual Inspection CMS
Date: Feb 3, 2023
Visit Reason
The survey was a recertification and abbreviated survey conducted to assess compliance with regulatory requirements for nursing home operations, including resident care, environment, medication management, infection control, and staff training.
Findings
The facility was found deficient in multiple areas including environmental maintenance and cleanliness, failure to provide scheduled personal hygiene and showering for residents, unsecured resident wardrobes posing accident hazards, medication regimen irregularities and errors, failure to provide food accommodating resident dietary needs, inadequate food service sanitation, delayed rehabilitation services, infection prevention and control lapses, pest control deficiencies, and incomplete staff orientation and training.
Citations (11)
F 0584: The facility did not maintain a safe, clean, and homelike environment; multiple units had urine odors, unclean floors, damaged walls, missing tiles, exposed insulation, and unlabeled personal care items in shared bathrooms.
F 0677: The facility failed to provide necessary personal hygiene services including scheduled showers, hair washing, shaving, and nail care for 3 residents, despite care plans requiring these services.
F 0689: Resident room wardrobes were not secured to walls, creating a risk of toppling and accident hazards across multiple units; facility completed securing wardrobes after survey.
F 0756: The facility did not ensure pharmacist-identified medication irregularities were reviewed and acted upon timely for Resident #12, resulting in insulin administration outside ordered parameters on multiple occasions.
F 0760: Resident #12 received insulin outside physician ordered blood sugar parameters on 62 occasions between October 2022 and January 2023, constituting significant medication errors.
F 0806: Resident #12 was not provided Lactaid milk and diet hot chocolate as documented on meal tickets on 1/25/2023 and 1/26/2023, failing to accommodate dietary preferences and restrictions.
F 0812: The facility failed to maintain food service safety standards; the dishwasher final rinse temperature was inadequate, dishware was stored uncovered, and nourishment rooms and kitchen equipment were dirty and in disrepair.
F 0825: Resident #41 did not receive timely physical and occupational therapy screens following a referral made on 1/23/2023, delaying specialized rehabilitative services.
F 0880: The facility failed to ensure proper hand hygiene and clean technique during wound care for Resident #38, and staff did not consistently wear masks properly to prevent infection spread.
F 0925: The facility did not maintain an effective pest control program; flies were observed in multiple locations on Units C and G, with no timely follow-up or documentation of pest control measures.
F 0940: The facility did not ensure all new and existing staff completed general orientation training as required by facility policy; multiple employee files lacked documentation of completed orientation components.
Report Facts
Insulin administration outside parameters: 62
Resident units with unsecured wardrobes: 5
Employee files reviewed: 7
Flies observed in room C 63: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in wound care procedure deficiencies and failure to maintain hand hygiene. |
| LPNUM #5 | Licensed Practical Nurse Unit Manager | Named in wound care procedure deficiencies and failure to maintain hand hygiene. |
| Director of Maintenance | Named in unsecured wardrobes and pest control deficiencies. | |
| Director of Nursing | DON | Named in medication irregularities, wound care training, and staff orientation deficiencies. |
| Food Service Director | FSD | Named in food service safety and dietary accommodation deficiencies. |
| Registered Nurse Unit Manager | RNUM | Named in personal hygiene deficiencies. |
| Certified Nursing Assistant #1 | CNA | Observed with improper mask use. |
| Certified Occupational Therapy Aide | Observed with improper mask use. | |
| Director of Recreation | DR | Observed with improper mask use. |
| Onboarding Specialist | OS | Named in staff orientation process and training deficiencies. |
Inspection Report — Sep 16, 2020
Annual Inspection CMS
Date: Sep 16, 2020
Visit Reason
The survey was a recertification annual inspection to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including environmental maintenance, abuse reporting, resident assessments, care planning, nutrition management, dialysis care, dementia care, medication administration, infection control, and medical record documentation.
Citations (17)
F 0584: The facility did not provide effective maintenance and pest control services; floors were soiled, walls were in disrepair, and fly activity was observed on multiple units.
F 0609: The facility failed to timely report an alleged incident of staff screaming at a resident to the administrator as required by state law.
F 0641: The facility did not ensure accurate resident assessments for 3 residents; MDS data did not reflect true cognitive or functional status or pressure ulcer stage.
F 0655: The facility did not develop and implement baseline care plans within 48 hours of admission for 4 residents and did not provide summaries to residents or representatives.
F 0656: The facility did not develop and implement comprehensive person-centered care plans with measurable objectives for 9 residents, including care for sensitive skin, pressure ulcers, infections, and dementia-related behaviors.
F 0692: The facility did not maintain acceptable nutritional status for 2 residents; significant weight loss was not recognized, evaluated, or addressed appropriately.
F 0698: The facility did not ensure dialysis care was consistent with professional standards; communication with dialysis center was lacking and fluid restriction orders were not transcribed or monitored.
F 0744: The facility did not provide person-centered dementia care plans with individualized interventions for 2 residents with dementia.
F 0758: The facility did not limit PRN psychotropic medication orders to 14 days or document rationale for extension for 1 resident.
F 0759: The facility's medication error rate was 33.33% with late administration, refusal not documented, and medications withheld without physician notification for 4 residents.
F 0761: The facility did not maintain drugs and biologicals properly; expired medications were found in medication rooms and carts on multiple units.
F 0773: The facility did not promptly notify the physician of critical lab results indicating likely congestive heart failure for 1 resident; notification was delayed by 6 days.
F 0791: The facility did not provide routine annual dental services for 1 resident; no documentation of refusal was found.
F 0806: The facility did not ensure residents received food accommodating allergies, intolerances, and preferences; residents were not offered alternative meals or choices.
F 0812: The facility's automatic dishwashing machine was not operating at the required final rinse temperature to sanitize food surfaces.
F 0842: The facility did not maintain complete, accurate, and accessible medical records for 5 residents; documentation was missing, altered, or incomplete for treatments, ADLs, weights, and wound care.
F 0880: The facility failed to maintain infection prevention and control standards; hand hygiene was not performed appropriately, multi-use equipment was not sanitized between residents, and contaminated wound supplies were improperly stored.
Report Facts
Medication error rate: 33.33
Weight loss: 25.4
Weight loss: 21.6
Lab notification delay: 6
Treatment documentation omissions: 24
CNA ADL documentation omissions: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control and medication administration findings |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and hand hygiene findings |
| LPN #3 | Licensed Practical Nurse | Named in medication administration findings |
| LPN #4 | Licensed Practical Nurse Acting Unit Manager | Named in multiple findings including medication administration, documentation, and nutrition |
| LPN #7 | Licensed Practical Nurse | Named in treatment administration documentation finding |
| LPN #8 | Licensed Practical Nurse | Named in lab notification and infection control findings |
| LPN #10 | Licensed Practical Nurse | Named in dialysis care findings |
| RNUM #1 | Registered Nurse Unit Manager | Named in medication administration and infection control findings |
| CNA #2 | Certified Nursing Assistant | Named in ADL documentation and infection control findings |
| CNA #4 | Certified Nursing Assistant | Named in infection control findings |
| Director of Nursing | Director of Nursing | Named in multiple findings including infection control, documentation, nutrition, and dialysis care |
| Director of Food Services | Director of Food Services | Named in food safety finding |
| Corporate Registered Dietician | Registered Dietician | Named in nutrition findings |
| Physician #10 | Physician | Named in lab notification and medication findings |
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