Inspection Reports for Sans Souci Rehabilitation and Nursing Center
115 Park Avenue, Yonkers, NY, 10703
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
16.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
229% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
110 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Sep 8, 2025
Visit Reason
The abbreviated survey was conducted to investigate allegations of abuse, neglect, mistreatment, and pain management concerns for Resident #1 at Sans Souci Rehabilitation and Nursing Center.
Complaint Details
The visit was complaint-related, triggered by allegations of abuse and neglect involving Licensed Practical Nurse #1 and Resident #1. The complaint was substantiated based on video surveillance, interviews, and record review showing inappropriate physical interaction and refusal to timely administer pain medication.
Findings
The facility failed to protect Resident #1 from abuse and neglect by Licensed Practical Nurse #1, who was observed on video attempting to forcefully move the resident against their will and refusing timely administration of pain medication. The facility also failed to thoroughly investigate the alleged abuse, omitting video evidence and not interviewing a key witness. Resident #1 experienced delayed pain medication administration, receiving medication over eight hours after the prior dose.
Deficiencies (3)
Failure to protect Resident #1 from all types of abuse including physical and neglect.
Failure to respond appropriately to all alleged violations involving abuse, neglect, or mistreatment.
Failure to provide safe, appropriate pain management for Resident #1, resulting in delayed administration of pain medication.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Pain medication delay: 8.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in abuse and neglect findings for forcefully moving Resident #1 and refusing timely pain medication |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Witnessed and intervened during incident involving Resident #1 and Licensed Practical Nurse #1 |
| Director of Nursing | Director of Nursing | Acknowledged failures in handling the incident and investigation |
| Certified Nurse Aide #1 | Certified Nurse Aide | Reported witnessing the incident and yelling between Licensed Practical Nurse #1 and Resident #1 |
Inspection Report
Abbreviated Survey
Census: 110
Deficiencies: 5
Date: Apr 22, 2025
Visit Reason
The facility underwent an abbreviated survey to assess compliance with care standards including activities of daily living, nutrition, staffing, medication administration, and wound care.
Findings
The survey found deficiencies in activities of daily living care, significant weight loss and poor nutritional intake for Resident #5, inadequate staffing levels especially nursing coverage, and multiple significant medication administration errors affecting several residents. Documentation inconsistencies and failure to provide ordered care were noted.
Deficiencies (5)
Failure to provide consistent activities of daily living care including incontinence care, showers, personal hygiene, and assistance during meals for Residents #5 and #6.
Failure to provide appropriate treatment and care according to orders for Resident #1 with a reopened stage 2 pressure ulcer, including turning and repositioning every 1-2 hours.
Failure to maintain acceptable nutritional status for Resident #5 with a 15% weight loss in 30 days and inconsistent documentation of intake.
Insufficient nursing and certified nurse assistant staffing levels on multiple shifts in January and February 2024, including shifts with no nurse coverage.
Significant medication errors on 2/25/2024 when no nurse was present on the second floor during the 7 AM to 3 PM shift, resulting in 36 residents missing medications including critical drugs such as insulin, anticoagulants, and antihypertensives.
Report Facts
Residents dressed in gowns: 22
Residents dressed in gowns: 33
Resident #5 bladder and bowel incontinence care missed: 19
Resident #6 bladder and bowel incontinence care missed: 35
Resident #5 weight loss percentage: 15
Resident #5 weight measurements: 100
Resident #5 weight measurements: 81.8
Staffing counts: 1
Staffing counts: 2
Residents missing medications: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding residents' preference for wearing gowns and care planning. |
| Director of Nursing #2 | Director of Nursing | Provided oversight statements on CNA documentation and staffing; interviewed about medication error incident. |
| Assistant Director of Nursing #2 | Assistant Director of Nursing | Provided statements on CNA documentation oversight and staffing. |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed about documentation and care provision for turning and repositioning. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed about documentation and care provision for turning and repositioning. |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed about documentation and care provision for turning and repositioning. |
| Licensed Practical Nurse Unit Manager #1 | Licensed Practical Nurse Unit Manager | Interviewed about staff knowledge and documentation of turning and repositioning. |
| Registered Dietician | Registered Dietician | Interviewed about Resident #5's nutritional challenges and interventions. |
| Director of Human Resources | Director of Human Resources | Interviewed about staffing schedules and use of agency staff. |
| Regional Medical Director | Regional Medical Director | Interviewed about medication error incident and clinical significance. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 5
Date: Apr 22, 2025
Visit Reason
Multiple Level 2 standard health citations related to ADL care, nutrition, quality of care, medication errors, and nursing staff sufficiency with no actual harm but potential for minor discomfort.
Findings
Multiple Level 2 standard health citations related to ADL care, nutrition, quality of care, medication errors, and nursing staff sufficiency with no actual harm but potential for minor discomfort.
Deficiencies (5)
ADL care provided for dependent residents
Nutrition/hydration status maintenance
Quality of care
Residents are free of significant med errors
Sufficient nursing staff
Inspection Report
Abbreviated Survey
Deficiencies: 6
Date: Apr 15, 2025
Visit Reason
The abbreviated survey was conducted to investigate allegations of abuse, neglect, and compliance with reporting and care planning requirements at Sans Souci Rehabilitation and Nursing Center.
Findings
The facility failed to ensure residents' rights to be free from abuse, timely reporting of investigations, thorough investigations of abuse allegations, accurate resident assessments, comprehensive care planning, and adequate supervision to prevent accidents. Several residents were involved in incidents of alleged abuse or elopement, with deficiencies noted in investigation documentation, reporting, and care planning.
Deficiencies (6)
Failure to protect residents from abuse; specifically, Resident #2 struck Resident #3 with a flexi-bar but the investigation concluded no abuse occurred.
Failure to timely report the results of investigations to the New York State Department of Health within 5 working days for incidents involving Residents #2, #3, and #4.
Failure to thoroughly investigate allegations of abuse for 6 residents, including incomplete staff statements and unsigned investigative summaries.
Failure to ensure accurate resident assessments; Resident #4 with a history of wandering was not identified as at risk for elopement on admission.
Failure to develop and implement a comprehensive care plan for Resident #4, specifically lacking a wandering or elopement risk care plan.
Failure to provide adequate supervision and maintain a resident environment free from accident hazards; Resident #4 exited the facility unescorted and wandered into a neighboring home.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 6
Cash missing: 33
Cash App transfer: 65
ATM withdrawal: 46
Elopement risk score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Witnessed Resident #2 striking Resident #3 with a flexi-bar | |
| Certified Nurse Aide #2 | Witnessed Resident #2 striking Resident #3 with a flexi-bar | |
| Director of Nursing #1 | Director of Nursing | Determined no abuse occurred in Resident #2 and Resident #3 incident; responsible for reporting and investigation oversight |
| Licensed Practical Nurse #1 | Reported Resident #1's allegation of inappropriate touching by Resident #2 | |
| Registered Nurse #1 | Responded to Resident #1's allegation and interviewed involved residents | |
| Administrator | Administrator | Involved in reporting to Department of Health and investigation oversight |
| Admissions Director | Responsible for reviewing resident admission packets and assessments | |
| Receptionist | Buzzed Resident #4 out of the facility on 1/14/2024, unaware resident was a patient | |
| Director of Nursing #2 | Director of Nursing | Conducted Resident #4's admission assessment and involved in elopement incident response |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Apr 15, 2025
Visit Reason
Several Level 2 standard health citations related to assessment accuracy, care planning, abuse prevention, accident hazards, investigation and reporting of violations, all corrected by May 16, 2025.
Findings
Several Level 2 standard health citations related to assessment accuracy, care planning, abuse prevention, accident hazards, investigation and reporting of violations, all corrected by May 16, 2025.
Deficiencies (6)
Accuracy of assessments
Develop/implement comprehensive care plan
Free from abuse and neglect
Free of accident hazards/supervision/devices
Investigate/prevent/correct alleged violation
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Census: 120
Capacity: 120
Deficiencies: 7
Date: Aug 14, 2024
Visit Reason
The survey was conducted as a recertification and abbreviated survey from 8/6/2024 to 8/14/2024 to assess compliance with regulatory requirements including grievance resolution, discharge planning, pressure ulcer care, pain management, staffing adequacy, behavioral health care, and rehabilitative services.
Findings
The facility was found deficient in multiple areas including failure to promptly resolve resident grievances, ineffective discharge planning, inadequate pressure ulcer care, insufficient pain management, inadequate nursing staffing levels, failure to provide individualized behavioral health care, and failure to provide required rehabilitative services such as speech therapy evaluation.
Deficiencies (7)
Failure to ensure prompt resolution of a resident's grievance and establish a grievance policy including all necessary elements.
Failure to ensure an effective discharge planning process focused on resident's discharge goals and involvement of resident and representative.
Failure to provide necessary treatment and services for an existing pressure injury, including timely assessment and physician notification.
Failure to provide safe, appropriate pain management consistent with professional standards and care plans for residents requiring such services.
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Failure to ensure each resident received necessary behavioral health care and services to attain or maintain highest practicable well-being.
Failure to provide or get specialized rehabilitative services as required, specifically failure to complete speech therapy evaluation for slow eating and chewing.
Report Facts
Residents sampled: 25
Resident census: 120
Certified Nursing Assistant hours per resident per day: 2.2
Weight loss percentage: 7.5
Weight loss percentage: 10.5
Certified Nursing Assistants: 9
Certified Nursing Assistants: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Work | Interviewed regarding grievance resolution and discharge planning for Resident #10 | |
| Administrator | Interviewed regarding grievance resolution, discharge planning, staffing, and behavioral health care | |
| Licensed Practical Nurse #11 | Interviewed regarding pain management for Resident #88 | |
| Physician Assistant | Interviewed regarding pain management and behavioral health care for Resident #10 and #88 | |
| Certified Nursing Assistant #8 | Interviewed regarding care for Resident #10 and #8 | |
| Certified Nursing Assistant #22 | Interviewed regarding staffing and resident care on 2nd Floor | |
| Certified Nursing Assistant #23 | Interviewed regarding staffing and call outs on 2nd and 3rd Floors | |
| Licensed Practical Nurse #10 | Interviewed regarding staffing and resident care on 3rd Floor | |
| Director of Nursing | Interviewed regarding pressure ulcer care, pain management, staffing, and behavioral health care | |
| Speech Therapist #17 | Interviewed regarding speech therapy evaluation for Resident #81 | |
| Occupational Therapist | Interviewed regarding speech therapy evaluation for Resident #81 | |
| Clinical Nutrition Manager | Interviewed regarding weight loss and nutritional risk for Resident #81 | |
| Licensed Practical Nurse #13 | Interviewed regarding medication refill for Resident #213 | |
| Director of Rehabilitation | Interviewed regarding referral to Physiatrist for pain management | |
| Licensed Practical Nurse #21 | Interviewed regarding staffing and resident care on 3rd Floor | |
| Certified Nursing Assistant #22 | Interviewed regarding staffing and resident care on 2nd Floor |
Inspection Report
Annual Inspection
Census: 120
Capacity: 120
Deficiencies: 12
Date: Aug 14, 2024
Visit Reason
Recertification and abbreviated survey conducted from 08/06/2024 to 08/14/2024 to assess compliance with regulatory requirements for Sans Souci Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including grievance policy and resolution, discharge planning, activities of daily living care, pressure ulcer care, pain management, physician review of care, staffing adequacy, behavioral health care, medication administration, infection control, specialized rehabilitative services, and vaccination policies.
Deficiencies (12)
Failure to ensure prompt resolution of resident grievances and establish a grievance policy including all necessary elements.
Failure to ensure an effective discharge planning process focused on resident's goals and needs, involving resident and representative.
Failure to provide timely assistance with activities of daily living, specifically incontinence care for Resident #95.
Failure to provide necessary treatment and services for an existing pressure injury, including timely assessment and physician notification.
Failure to provide safe and appropriate pain management consistent with professional standards and care plans for Residents #88 and #213.
Failure to ensure physician reviewed resident's total program of care, including pain management recommendations and nursing evaluations, at each visit for Resident #88.
Failure to provide sufficient nursing staff to meet residents' needs on 2nd and 3rd floors, resulting in delays in care and resident complaints.
Failure to ensure each resident received behavioral health care and services to maintain highest practicable well-being; Resident #10's behavioral health plan was not individualized or revised to address symptoms.
Failure to ensure medication error rate was below 5%; Resident #5 was administered crushed enteric coated aspirin and crushed delayed release Depakote.
Failure to provide and implement infection prevention and control practices including proper hand hygiene during meal service and wound care.
Failure to provide or get specialized rehabilitative services as ordered; Speech Therapy evaluation for Resident #81 was not completed.
Failure to develop and implement policies and procedures ensuring residents were offered pneumococcal immunizations with education on benefits and side effects; Resident #51 had no documented offer or education.
Report Facts
Medication error rate: 8
Resident census: 120
Facility capacity: 120
Certified Nursing Assistant hours per resident per day: 2.2
Weight loss percentage: 7.5
Weight loss percentage: 10.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #14 | Administered crushed enteric coated aspirin and crushed Depakote to Resident #5 | |
| Licensed Practical Nurse #11 | Interviewed regarding pain management for Resident #88 and wound care hand hygiene | |
| Director of Nursing | Interviewed regarding medication administration, staffing, infection control, and pain management | |
| Physician Assistant | Interviewed regarding pain management and behavioral health care for Resident #88 and Resident #10 | |
| Certified Nursing Assistant #8 | Interviewed regarding care of Resident #10 and staffing concerns | |
| Certified Nursing Assistant #23 | Interviewed regarding staffing shortages on 2nd and 3rd floors | |
| Certified Nursing Assistant #22 | Interviewed regarding resident toileting assistance on 2nd floor | |
| Licensed Practical Nurse #10 | Interviewed regarding staffing and assistance with activities of daily living | |
| Clinical Nutrition Manager | Interviewed regarding Resident #81 weight loss | |
| Occupational Therapist | Interviewed regarding speech therapy evaluation for Resident #81 | |
| Speech Therapist #17 | Interviewed regarding speech therapy screening for Resident #81 | |
| Certified Nurse Aide #1 | Observed touching resident food during meal service | |
| Licensed Practical Nurse #21 | Interviewed regarding staffing and call outs | |
| Administrator | Interviewed regarding staffing and behavioral health care | |
| Director of Social Work | Interviewed regarding behavioral health care and grievance process | |
| Infection Preventionist | Interviewed regarding vaccination and infection control practices |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jul 30, 2024
Visit Reason
The inspection was conducted as an abbreviated survey to investigate allegations of abuse and to assess compliance with care plan requirements related to pressure injury prevention.
Complaint Details
The complaint investigation found substantiated verbal abuse of Resident #3 by Dietary Aide #15 on 2/21/24, witnessed by Certified Nurse Aide #14. The facility conducted an investigation, notified police, and asked the Dietary Aide to leave the building.
Findings
The facility failed to protect a resident from verbal abuse by a staff member and did not develop or implement a comprehensive person-centered care plan for another resident, specifically failing to offload heels or apply heel booties as ordered.
Deficiencies (2)
Failure to protect Resident #3 from verbal abuse by Dietary Aide #15, including pulling on a beaded necklace and verbal threats.
Failure to develop and implement a complete care plan for Resident #1, including not offloading heels or applying heel booties as per physician orders and care plan.
Report Facts
Residents affected: 1
Residents affected: 1
Date of abuse incident: Feb 21, 2024
Date of interviews: Jul 24, 2024
Date of care plan: Jul 7, 2023
Date of physician order: Sep 19, 2023
Date of physician order: Oct 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #14 | Certified Nurse Aide | Witnessed abuse incident and reported it |
| Dietary Aide #15 | Dietary Aide | Alleged perpetrator of verbal abuse |
| Certified Nursing Assistant #11 | Certified Nursing Assistant | Interviewed regarding care plan implementation for Resident #1 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding care plan implementation for Resident #1 |
| Registered Nurse Supervisor #17 | Registered Nurse Supervisor | Reported investigation actions and notification of police |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jul 30, 2024
Visit Reason
Level 2 citations for care plan development and abuse prevention, corrected by September 19, 2024.
Findings
Level 2 citations for care plan development and abuse prevention, corrected by September 19, 2024.
Deficiencies (2)
Develop/implement comprehensive care plan
Free from abuse and neglect
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Feb 8, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to evaluate the facility's compliance with nursing staff competencies and medication administration safety, triggered by concerns regarding medication errors for a resident.
Findings
The facility failed to ensure nursing staff had the appropriate competencies to safely care for residents, resulting in a medication error where incorrect medication orders were uploaded into a resident's electronic medical record, leading to the resident receiving wrong medications for several days. The error was discovered after the resident's family alerted the facility, and corrective actions including staff re-education and revised admission checklists were implemented.
Deficiencies (2)
Nursing staff failed to possess the competency and skill set necessary to provide nursing and related services safely, resulting in a medication error for 1 of 3 residents reviewed.
Residents were not free from significant medication errors; Resident #1 received medications not prescribed due to wrong information uploaded into the EMR.
Report Facts
Medication error duration: 4
Medication error rate: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services (DNS) | Interviewed regarding medication error and facility response |
| Registered Nurse Supervisor | Registered Nurse Supervisor (RNS) | Responsible for uploading admission information into EMR and interviewed about the medication error |
| Physician Assistant | Physician Assistant (PA) | Interviewed about resident assessment and medication error notification |
| Physician | Physician (MD) | Interviewed about medication review process and notification of medication error |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Feb 8, 2023
Visit Reason
Level 2 citations for competent nursing staff and medication error prevention, corrected by March 10, 2023.
Findings
Level 2 citations for competent nursing staff and medication error prevention, corrected by March 10, 2023.
Deficiencies (2)
Competent nursing staff
Residents are free of significant med errors
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 23, 2021
Visit Reason
Level 2 citation for free from involuntary seclusion, corrected by January 15, 2022.
Findings
Level 2 citation for free from involuntary seclusion, corrected by January 15, 2022.
Deficiencies (1)
Free from involuntary seclusion
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Oct 27, 2021
Visit Reason
The inspection was a recertification survey conducted to assess compliance with federal regulations including privacy, staffing, food safety, and infection control.
Findings
The facility was found deficient in maintaining resident privacy by placing opposite sex residents in adjoining rooms with a shared bathroom. Staffing information was incomplete and not posted accurately. Food safety practices were inadequate due to unlabeled and undated food items. Infection prevention and control practices were deficient, including uncovered catheter drainage bags and uncovered oxygen tubing.
Deficiencies (4)
Privacy was not maintained for residents of opposite sex sharing a bathroom.
Facility did not post accurate nurse staffing information daily and could not provide complete staffing records for 18 months.
Prepared and frozen foods in kitchen refrigerator and dry food storage were not labeled or dated.
Foley catheter drainage bags were observed uncovered and on the floor; oxygen tubing and humidification bottles were uncovered and undated.
Report Facts
Deficiencies cited: 4
Staffing records missing: 18
Dates of observations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager | RNUM #1 | Interviewed about bathroom sharing oversight and oxygen tubing change frequency |
| Director of Social Work | DSW | Interviewed about room placement decisions for residents |
| Staffing Coordinator | Staffing Coordinator #1 | Interviewed about missing staffing records and form completion |
| Director of Nursing | DON | Interviewed about staffing form process and infection control education |
| Dietary Director | Dietary Director | Interviewed about food labeling and dating practices |
| Dietary Cook | Dietary Cook | Interviewed about defrosted meat handling |
| Certified Nursing Assistant | CNA #5 | Interviewed about catheter care |
| LPN | LPN #10 | Interviewed about oxygen tubing maintenance |
| Respiratory Therapist | Respiratory Therapist #1 | Interviewed about oxygen tubing change schedule |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 13
Date: Oct 27, 2021
Visit Reason
Multiple Level 2 standard health and life safety code citations related to criminal history checks, food sanitation, infection control, notifications, privacy, nurse staffing info, and building safety features, all corrected by December 24, 2021.
Findings
Multiple Level 2 standard health and life safety code citations related to criminal history checks, food sanitation, infection control, notifications, privacy, nurse staffing info, and building safety features, all corrected by December 24, 2021.
Deficiencies (13)
Criminal history record check process
Food procurement,store/prepare/serve-sanitary
Infection prevention & control
Notify of changes (injury/decline/room, etc.)
Personal privacy/confidentiality of records
Posted nurse staffing information
Requirements before submitting a request for
Corridors - construction of walls
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Fundamentals - building system categories
Local, state, tribal collaboration process
Maintenance, inspection & testing - doors
Inspection Report
Annual Inspection
Deficiencies: 14
Date: Aug 7, 2018
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for Sans Souci Rehabilitation and Nursing Center.
Findings
The survey identified multiple deficiencies including failure to ensure residents' rights regarding advance directives, inadequate abuse reporting policies, untimely Minimum Data Set submissions, lack of communication aids for a resident with a tracheostomy, incomplete skin care treatments, failure to arrange audiology consults, inadequate bladder incontinence care planning, lack of coordination in fluid management, insufficient pain management, delayed dental services, inconsistent provision of evening snacks, medication errors exceeding 5%, and infection control lapses including improper storage of supplies and resident handling of tracheostomy without hand hygiene.
Deficiencies (14)
Failure to ensure residents or their representatives were given the opportunity to formulate advance directives.
Failure to implement policies and procedures for reporting allegations of abuse.
Failure to submit Minimum Data Set assessments electronically within required timeframes.
Failure to provide a communication device for a resident with a tracheostomy to speak normally.
Failure to provide appropriate treatment to prevent skin breakdown and recurrence of chronic skin irritation.
Failure to arrange audiology evaluation as ordered for a resident.
Failure to develop a patient-centered care plan addressing urinary incontinence and promote continence.
Failure to coordinate nursing and dietary to ensure fluid intake did not exceed physician's order.
Failure to provide ongoing evaluation and management of pain for a resident.
Failure to provide medical supervision addressing significant unplanned weight loss and abnormal lab values.
Failure to provide timely dental services including arrangements for dentures.
Failure to ensure residents were consistently offered and provided evening snacks.
Medication error rate exceeded 5% with errors including wrong supplement and incorrect medication strength/dosage.
Failure to implement infection prevention and control measures including improper storage of supplies on the floor and resident handling tracheostomy tube with bare fingers without hand hygiene.
Report Facts
Medication error rate: 9.6
Weight loss percentage: 22.4
Fluid restriction: 1200
MDS submission delay: 3
Residents reporting no evening snacks: 7
Residents receiving evening snacks: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Administered wrong supplement medication to Resident #267 |
| LPN #3 | Licensed Practical Nurse | Administered incorrect strength and dosage of medications to Resident #38 |
| Social Worker | Interviewed regarding advanced directives, voice box ordering, and hearing aid consultation | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including infection control and resident communication |
| Respiratory Therapist | RT | Interviewed regarding tracheostomy care and communication device for Resident #5 |
| Director of Rehabilitation | DR | Interviewed regarding speech therapy and pain management |
| Physician MD #1 | Attending Physician | Interviewed regarding audiology consult and pain management |
| Physician MD #2 | Attending Physician | Interviewed regarding voice box for Resident #5 |
| Physician MD #3 | Physician | Interviewed regarding weight loss and abnormal lab values for Resident #45 |
| Licensed Practical Nurse #5 | LPN | Interviewed regarding skin care and dental services |
| Registered Nurse #1 | RN | Interviewed regarding medication storage and emergency equipment |
| Certified Nursing Aide #7 | CNA | Interviewed regarding skin care observations |
| Certified Nursing Aide #9 | CNA | Interviewed regarding urinary incontinence care |
| Certified Nursing Aide #10 | CNA | Interviewed regarding urinary incontinence care |
| Food Service Director | FSD | Interviewed regarding evening snack availability |
| Registered Dietitian | RD | Interviewed regarding nutrition and fluid management |
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