Inspection Reports for Martine Center for Rehabilitation and Nursing
12 Tibbits Ave, White Plains, NY 10606, NY, 10606
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
125% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Abbreviated Survey
Deficiencies: 3
Aug 25, 2025
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate compliance with care planning, resident safety, and environmental conditions at Martine Center for Rehabilitation and Nursing.
Findings
The facility failed to develop and implement comprehensive person-centered care plans for several residents, did not ensure adequate supervision to prevent accidents resulting in a resident fall, and maintained an environment with multiple maintenance deficiencies including chipped paint, dirt, and pest sightings.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to develop and implement a complete care plan that meets all the resident's needs, with timetables and measurable actions for 3 of 5 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure the resident environment remained free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident fall with skin tears. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a safe, easy to use, clean and comfortable environment with multiple areas of chipped paint, scuff marks, visible dirt, baseboards peeling, wallpaper bubbling, foul odors, and pest sightings. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care planning: 5
Residents affected by care plan deficiency: 3
Residents affected by accident hazard deficiency: 1
Residents affected by environmental deficiency: Some
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Named in fall incident where resident was left unattended resulting in fall and skin tears | |
| Registered Nurse #1 | Registered Nurse | Responsible for incident report and updating fall care plans |
| Director of Nursing #1 | Director of Nursing | Acknowledged care plan deficiencies for Resident #5 |
| Director of Nursing #2 | Director of Nursing | Interviewed regarding fall incident and care plan updates |
| Registered Nurse #3 | Registered Nurse | Responsible for pressure injury assessment and care plan updates for Resident #2 |
| Administrator | Administrator | Provided information on environmental rounds and resident safety |
| Director of Environmental/Housekeeping | Director of Environmental/Housekeeping | Provided details on maintenance deficiencies and pest control |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Dec 5, 2024
Visit Reason
The inspection was conducted as an abbreviated survey focusing on allegations of abuse, neglect, and elopement risk for Resident #1, triggered by a reported incident of the resident leaving the facility undetected.
Findings
The facility failed to timely report an elopement incident involving Resident #1 to the New York State Department of Health within the required 2-hour timeframe. Resident #1, identified as high risk for elopement, left the facility undetected on 11/26/2024 and was found in Los Angeles days later. The facility also failed to provide adequate supervision to prevent the elopement and did not complete annual performance appraisals for two Certified Nurse Aides.
Complaint Details
The visit was complaint-related, triggered by an incident where Resident #1, identified as high risk for elopement, left the facility undetected on 11/26/2024. The facility became aware of the incident late that day and reported it to the New York State Department of Health on 11/27/2024 at 1:11 AM. The investigation revealed inadequate supervision and delayed reporting.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft to proper authorities within 2 hours. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision to prevent accidents, specifically elopement of Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete annual performance appraisals for Certified Nurse Aides #2 and #3. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Date of incident: Nov 26, 2024
Date of report to State Agency: Nov 27, 2024
BIMS score: 10
Elopement risk score: 16
Certified Nurse Aide #2 hire date: Jul 1, 2022
Certified Nurse Aide #3 hire date: Jun 20, 2017
Last performance evaluation date for CNA #3: Sep 5, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #1 | Mentioned in statements regarding Resident #1's care and elopement incident | |
| Certified Nurse Assistant #2 | Mentioned in statements regarding Resident #1's care and elopement incident; noted missing annual performance appraisal | |
| Certified Nurse Assistant #3 | Mentioned in statements regarding Resident #1's care and elopement incident; noted missing annual performance appraisal | |
| Licensed Practical Nurse #5 | Mentioned in statements regarding Resident #1's care and elopement incident | |
| Director of Nursing | Director of Nursing | Responsible for reporting incident and providing statements about supervision and facility policies |
| Administrator | Administrator | Provided multiple interviews regarding incident details and facility policies |
| Director of Human Resources | Director of Human Resources | Provided interview regarding employee performance evaluations |
| Receptionist #4 | Provided statement about Resident #1's presence in lobby on day of incident | |
| Social Worker | Provided interview about Resident #1's care plan and behavior |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Dec 5, 2024
Visit Reason
Complaint survey with 3 health deficiencies and no life safety code deficiencies; all corrected by January 9, 2025.
Findings
Complaint survey with 3 health deficiencies and no life safety code deficiencies; all corrected by January 9, 2025.
Deficiencies (3)
| Description | Severity |
|---|---|
| Free of accident hazards/supervision/devices | Level 2 |
| Nurse aide peform review-12 hr/yr in-service | Level 2 |
| Reporting of alleged violations | Level 2 |
Inspection Report
Abbreviated Survey
Deficiencies: 4
Oct 1, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to assess compliance with regulatory requirements related to resident assessments, care planning, accident prevention, and supervision.
Findings
The facility failed to ensure accurate Minimum Data Set assessments and comprehensive, updated care plans for residents, resulting in inadequate documentation of required assistance levels. A resident fell from bed sustaining serious injuries due to insufficient supervision and failure to update care plans and task instructions. The facility environment was not free from accident hazards, and supervision was inadequate to prevent accidents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure accurate Minimum Data Set assessments reflecting resident status. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a comprehensive care plan that meets all resident needs with measurable timetables and actions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop the complete care plan within 7 days of comprehensive assessment and to review and revise it by a team of health professionals. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure the nursing home area is free from accident hazards and provide adequate supervision to prevent accidents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for assessments: 3
Residents affected: 1
Residents affected: 1
Length of laceration: 4.5
Depth of laceration: 0.1
Date of fall incident: Aug 21, 2024
Date of fall incident: Jul 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Named in fall incident involving Resident #1 and care provision |
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Interviewed regarding assistance required for Resident #1 |
| Certified Nurse Assistant #4 | Certified Nurse Assistant | Interviewed regarding assistance required for Resident #1 |
| Registered Nurse Minimum Data Set Coordinator | Registered Nurse | Interviewed regarding Minimum Data Set assessment process |
| Physical Therapist | Physical Therapist | Interviewed regarding evaluation and recommendations for resident assistance |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Primary nurse on duty during Resident #1 fall incident |
| Registered Nurse Unit Manager 4th floor | Registered Nurse Unit Manager | Responsible for updating care plan for Resident #2 fall |
| Medical Director | Medical Director | Interviewed regarding care planning and resident assistance levels |
| Director of Nursing | Director of Nursing | Interviewed regarding resident evaluation and care plan updates |
| Administrator | Administrator | Interviewed regarding incident review and care plan update process |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | On duty during Resident #1 fall incident and involved in emergency response |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 4
Oct 1, 2024
Visit Reason
Complaint survey with 5 health deficiencies related to assessments, care plans, and accident hazards; all corrected by October 29, 2024.
Findings
Complaint survey with 5 health deficiencies related to assessments, care plans, and accident hazards; all corrected by October 29, 2024.
Deficiencies (4)
| Description | Severity |
|---|---|
| Accuracy of assessments | Level 2 |
| Care plan timing and revision | Level 2 |
| Develop/implement comprehensive care plan | Level 2 |
| Free of accident hazards/supervision/devices | Level 2 |
Inspection Report
Annual Inspection
Deficiencies: 4
Dec 5, 2023
Visit Reason
The inspection was conducted as part of the Recertification and Abbreviated surveys from 11/27/2023 to 12/5/2023 to assess compliance with professional standards of care in the facility.
Findings
The facility failed to ensure appropriate treatment and care according to orders and resident preferences for 4 residents, including failure to document medication refusals, lack of evaluation of spitting behavior contributing to weight loss, multiple omissions of seizure medications, and failure to administer pain medication as ordered without notifying the medical provider.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Resident #578 refused medications and treatments, and the facility did not inform the health care provider or document refusals in the electronic medical record. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #87's spitting behavior was not evaluated to determine if it contributed to weight loss, and no interventions or physician notifications were documented. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #125 was not provided seizure medications as ordered for a total of 34 omissions in March 2023 without documented reasons. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #329 did not receive Dilaudid as ordered on 5/28/2023 and 5/30/2023, and the medical provider was not notified. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missed doses: 28
Missed doses: 25
Missed doses: 13
Omissions: 20
Weight loss: 18
Missed medication doses: 34
Missed medication doses: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #11 | Stated procedure for medication refusal and documentation | |
| Registered Nurse Unit Manager (RNUM) #1 | Described steps taken when resident refuses medication | |
| Director of Nursing (DON) | Reported audits and discussions regarding medication refusals | |
| Certified Nursing Assistant (CNA) #15 and #16 | Reported observations of Resident #87's spitting behavior and eating habits | |
| Registered Nurse (RN) #3 | Provided information on resident's eating assistance and lack of documentation on spitting | |
| Registered Dietitian (RD) | Reported lack of awareness of spitting behavior and resident's need for assistance | |
| Speech Language Pathologist (SLP) | Stated resident had not been evaluated for swallowing and spitting behavior | |
| Psychiatrist #1 | Not aware of spitting behavior and attributed it to mechanical problem rather than dementia | |
| Licensed Practical Nurse (LPN) #6 | Discussed medication supply and administration procedures |
Inspection Report
Annual Inspection
Deficiencies: 12
Dec 5, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 11/27/2023 to 12/5/2023 to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, honoring resident choices, beneficiary notification, safe and homelike environment maintenance, bed hold policy notification, accuracy of Minimum Data Set (MDS) assessments, care plan implementation and revision, medication administration and documentation, infection prevention and control, and staff performance evaluations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| The facility did not ensure a resident was assessed by the interdisciplinary team to determine the resident's ability to safely self-administer medications. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure that each resident had the right to make choices about significant aspects of life, specifically a resident's choice of when to get out of bed was not consistently honored. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not provide appropriate liability and appeal notices to Medicare beneficiaries for 2 of 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure a safe, clean, comfortable and homelike environment, with issues including loose toilet seats, unpainted walls, broken handrails, holes in walls, and urine odor in multiple rooms. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not provide timely written notice of the bed hold policy to residents or their representatives upon transfer to the hospital for 2 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure that resident Minimum Data Set (MDS) assessments accurately reflected the resident's status for 4 of 5 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure each resident had a person-centered comprehensive care plan implemented to address medical and physical needs, specifically proper footwear was not implemented for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not review and revise the comprehensive care plan with measurable objectives, time frames, and appropriate interventions for one resident, specifically the communication care plan did not reflect current status. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure residents received treatment and care according to orders and preferences, including failure to notify providers of medication refusals, failure to evaluate spitting behavior contributing to weight loss, multiple medication omissions, and failure to notify provider of missed pain medication. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure Certified Nurse Aide (CNA) performance reviews were completed at least once every 12 months for 4 of 5 CNAs reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure all drugs and biologicals were stored in locked compartments and labeled according to professional standards; medications were observed unsecured and unsupervised at residents' bedside and on meal trays. | Level of Harm - Minimal harm or potential for actual harm |
| The facility did not ensure staff maintained an infection prevention and control program, including failure to use personal protective equipment (PPE) and failure to use barriers when assisting residents with eating. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missed medication doses: 28
Missed medication doses: 25
Missed medication doses: 13
Missed medication doses: 20
Missed medication doses: 34
Weight loss: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Stated resident had nasal sprays and inhalers at bedside for about a year |
| Certified Nurse Aide #4 | Certified Nurse Aide | Reported not noticing medications at Resident #78's bedside |
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Observed leaving resident's room without ensuring medication swallowed |
| Certified Nurse Aide #10 | Certified Nurse Aide | Observed holding sandwich with bare hand while feeding Resident #131 |
| Certified Nurse Aide #1 | Certified Nurse Aide | Observed not using PPE while assisting Resident #59 on contact precautions |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Stated staff should use PPE and soap and water for handwashing for Resident #59 |
| Infection Control Practitioner | Infection Control Practitioner | Stated staff should use gowns, gloves, and soap and water for Resident #59 on contact precautions |
| Director of Nursing | Director of Nursing | Stated staff should use PPE for C-Diff and was unaware of bed hold policy not being given |
| Certified Nurse Aide #13 | Certified Nurse Aide | Aware resident needed shoes and socks and staff reminded resident to keep them on |
| Registered Nurse Unit Manager #3 | Registered Nurse Unit Manager | Stated resident had interventions to prevent falls including reminders to wear shoes or non-skid socks |
| MDS Coordinator | Acknowledged errors in MDS assessments and coding | |
| Director of Social Work | Director of Social Work | Stated bed hold was discontinued years ago and not their responsibility to notify residents |
| Administrator | Unaware bed hold policy was not given; stated evaluations should be done for CNAs | |
| Speech Language Pathologist | Speech Language Pathologist | Stated spitting behavior could indicate swallowing problems |
| Psychiatrist #1 | Psychiatrist | Not aware of spitting behavior; attributed it to mechanical problem and dysphagia |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Dec 5, 2023
Visit Reason
Complaint survey with 12 health deficiencies and 4 life safety code deficiencies; all corrected by January 23, 2024.
Findings
Complaint survey with 12 health deficiencies and 4 life safety code deficiencies; all corrected by January 23, 2024.
Deficiencies (16)
| Description | Severity |
|---|---|
| Accuracy of assessments | Level 2 |
| Care plan timing and revision | Level 2 |
| Develop/implement comprehensive care plan | Level 2 |
| Infection prevention & control | Level 2 |
| Label/store drugs and biologicals | Level 2 |
| Medicaid/medicare coverage/liability notice | Level 2 |
| Notice of bed hold policy before/upon trnsfr | Level 2 |
| Nurse aide peform review-12 hr/yr in-service | Level 2 |
| Quality of care | Level 2 |
| Resident self-admin meds-clinically approp | Level 2 |
| Safe/clean/comfortable/homelike environment | Level 2 |
| Self-determination | Level 2 |
| Electrical equipment - testing and maintenanc | Level 2 |
| Ep testing requirements | Level 1 |
| Fire alarm system - testing and maintenance | Level 2 |
| Portable fire extinguishers | Level 2 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Jun 1, 2022
Visit Reason
Complaint survey with 1 health deficiency related to discharge planning; corrected by June 24, 2022.
Findings
Complaint survey with 1 health deficiency related to discharge planning; corrected by June 24, 2022.
Deficiencies (1)
| Description | Severity |
|---|---|
| Discharge planning process | Level 2 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
May 26, 2022
Visit Reason
Complaint survey with 2 health deficiencies related to assessments and reporting of alleged violations; corrected by June 17, 2022.
Findings
Complaint survey with 2 health deficiencies related to assessments and reporting of alleged violations; corrected by June 17, 2022.
Deficiencies (2)
| Description | Severity |
|---|---|
| Accuracy of assessments | Level 2 |
| Reporting of alleged violations | Level 2 |
Inspection Report
Annual Inspection
Capacity: 200
Deficiencies: 7
Sep 24, 2020
Visit Reason
Recertification survey conducted to assess compliance with regulatory requirements including resident care, social work staffing, and emergency procedures.
Findings
The facility was found deficient in multiple areas including failure to ensure resident participation in care planning, failure to timely report a major injury fall, inadequate care planning for residents with contractures and post-operative care needs, failure to verify DNR orders prior to CPR, and failure to employ a qualified full-time social worker for a period of time.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to allow residents to participate in the development and implementation of person-centered plans of care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report an unwitnessed fall incident resulting in major injury to the state department of health. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a complete care plan with measurable objectives for residents in need of positioning devices to prevent contractures. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide basic life support including CPR in accordance with physician orders and resident advance directives, resulting in CPR initiated on a resident with DNR orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate post-operative assessment, care planning, and treatment for a resident after multiple surgeries. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care to maintain or improve range of motion and prevent contractures for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to employ a qualified full-time social worker for a licensed bed capacity of 200 for several months. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Licensed bed capacity: 200
Residents reviewed for contracture care: 4
Residents reviewed for advance directives: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SW #1 | Social Worker | Part-time social worker employed from 04/15/20 to 06/30/20 |
| SW #2 | Social Worker | Full-time social worker resigned effective 04/03/20 |
| SW #3 | Social Worker | Full-time social worker resigned effective 04/14/20 |
| SW #4 | Social Worker | Hired full-time on 06/30/20, no profile provided |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding fall incident reporting and care planning |
| Assistant Director of Nursing | ADN | Initiated CPR on resident with DNR order |
| Nurse Practitioner | NP | Interviewed regarding post-operative care and CPR incident |
| Social Worker | SW | Interviewed regarding resident participation in care planning |
| Director of Social Work | DSW | Interviewed regarding care planning scheduling |
Inspection Report
Annual Inspection
Deficiencies: 10
Jun 28, 2018
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in multiple areas including failure to notify residents or representatives of bed hold policies upon hospital transfer, lack of significant change assessments for pressure ulcers, incomplete care plans for incontinence, inconsistent diabetes management and medication administration, inadequate range of motion care, incomplete fall investigations, medication errors exceeding 5%, improper food storage and handling, and failure to follow infection control protocols.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to notify resident or representative in writing of bed hold policy upon hospital transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to conduct Significant Change MDS assessment for resident with pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop a comprehensive, person-centered care plan for bladder and bowel incontinence. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary care and treatment to prevent complications associated with hypo/hyperglycemia in a diabetic resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care and treatment for range of motion; left hand roll not applied as per care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to conduct thorough fall investigation including use of proper assistive devices and footwear. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to consistently provide prescribed pain medication (Morphine Sulfate) resulting in missed doses. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure medication error rate did not exceed 5%; observed medication errors during medication pass. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to procure, store, prepare, and serve food in accordance with professional standards; unlabeled, undated food and unclean refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow proper infection prevention and control practices including hand hygiene and equipment handling. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missed doses of morphine sulfate: 7
Medication error rate: 11
Blood sugar levels: 486
Blood sugar levels: 459
Blood sugar levels: 402
Blood sugar levels: 404
Blood sugar levels: 408
Blood sugar levels: 456
Blood sugar levels: 438
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN Manager #2 | Unit Registered Nurse Manager | Interviewed regarding toileting schedule initiation and medication administration issues. |
| LPN #1 | Licensed Practical Nurse | Observed and interviewed regarding medication administration and wound care practices. |
| LPN #2 | Licensed Practical Nurse | Observed and interviewed regarding medication administration errors. |
| Director of Social Work | DSW | Interviewed regarding notification of bed hold policy to residents or representatives. |
| Director of Nursing | DON | Interviewed regarding fall investigation and medication administration issues. |
| Nurse Practitioner | NP | Interviewed regarding missed morphine doses and diabetes management orders. |
| Certified Nursing Aide #1 | CNA | Interviewed regarding diabetes management and medication administration during out-of-pass. |
| Certified Nursing Aide #4 | CNA | Interviewed regarding left hand roll availability and use. |
| Director of Physical Therapy | DPT | Interviewed regarding resident's left hand roll use. |
| Unit Nurse Manager RN #1 | Registered Nurse | Interviewed regarding infection control and equipment handling. |
| Food Service Director | Interviewed regarding food storage and preparation policies. |
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