Inspection Reports for
Sarah Neuman Center for Rehabilitation and Nursing
845 Palmer Avenue, Mamaroneck, NY, 10543
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
20.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
296% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Abbreviated Survey
Census: 43
Deficiencies: 2
Date: Oct 23, 2025
Visit Reason
The abbreviated survey was conducted to assess the facility's compliance with safety and care standards, specifically focusing on accident hazards and supervision during resident transfers.
Findings
The facility failed to ensure a safe environment free from accident hazards and adequate supervision during resident transfers, resulting in actual harm to two residents due to improper use of mechanical lifts and unauthorized staff involvement. Additionally, the facility did not convene timely quality assurance meetings or fully implement corrective plans.
Deficiencies (2)
F 0689: The facility failed to ensure accident-free environment and adequate supervision during resident transfers, resulting in a hematoma for Resident #1 due to improper use of a Hoyer lift by unapproved staff and a swollen knee for Resident #2 due to transfer without required equipment and staff.
F 0867: The facility failed to establish an ongoing quality assessment and assurance group to review deficiencies and develop corrective plans, missing required meetings and failing to implement the directed Plan of Correction by the deadline.
Report Facts
Residents on unit during shift: 43
Certified Nurse Aides on shift: 4
Hematoma size: 0.5
Hematoma size: 0.5
Plan of Correction compliance date: Dec 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Involved in improper transfer of Resident #1 resulting in hematoma | |
| Private Aide #1 | Assisted Certified Nurse Aide #1 in transfer of Resident #1 without authorization | |
| Certified Nurse Aide #2 | Transferred Resident #2 alone without required equipment and staff assistance | |
| Registered Nurse Supervisor #1 | Documented incident reports and nursing progress notes related to Resident #1 | |
| Assistant Director of Nursing #1 | Provided interview statements regarding unauthorized staff involvement | |
| Licensed Practical Nurse #12 | Provided interview statements about staffing and rounding practices | |
| Registered Nurse Unit Manager #1 | Oversaw unit staff and provided interview statements on supervision and rounding | |
| Medical Doctor #1 | Provided medical assessment and interview statements regarding injuries and care expectations | |
| Registered Nurse #13 | Documented incident report for Resident #2 injury |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jun 4, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with care planning and accident prevention regulations for residents, specifically focusing on Resident #1's behavioral care plan and fall prevention.
Findings
The facility failed to develop and implement a comprehensive behavior/resistive to care plan for Resident #1 prior to 3/25/25 and did not ensure adequate supervision to prevent falls, resulting in Resident #1 sustaining a fall with head injury on 3/20/25.
Deficiencies (2)
F 0656: The facility did not ensure development and implementation of a comprehensive person-centered behavior care plan for Resident #1 prior to 3/25/25 despite a history of resistive behaviors.
F 0689: The facility failed to provide adequate supervision and effective use of monitoring to prevent falls for Resident #1, who fell in the bathroom on 3/20/25 causing a head abrasion with bleeding.
Report Facts
Residents reviewed for behaviors: 3
Residents reviewed for accidents: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Responsible for initiating and updating care plans; stated they are new and reviewing quarterly care plans |
| Director of Nursing | Director of Nursing | Provided statements regarding Resident #1's behavior, care plan initiation, and fall risk |
| Assistant Director of Nursing #1 | Assistant Director of Nursing | Reported on fall incident investigation and resident supervision requirements |
| Certified Nurse Aide #1 | Certified Nurse Aide | Observed Resident #1 fall in bathroom and described resident's resistive behaviors |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jun 4, 2025
Visit Reason
Two Level 2 standard health citations for developing and implementing comprehensive care plans and free of accident hazards, both isolated and without severe systemic problems.
Findings
Two Level 2 standard health citations for developing and implementing comprehensive care plans and free of accident hazards, both isolated and without severe systemic problems.
Deficiencies (2)
Develop/implement comprehensive care plan
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 14, 2025
Visit Reason
One Level 2 standard health citation for free from abuse and neglect, isolated and corrected.
Findings
One Level 2 standard health citation for free from abuse and neglect, isolated and corrected.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 14, 2025
Visit Reason
The abbreviated survey was conducted to investigate an allegation of abuse involving a Certified Nurse Aide pushing a resident, Resident #1, who is severely cognitively impaired.
Complaint Details
The complaint was substantiated based on the internal investigation and direct observation by Registered Nurse Supervisor #1. Certified Nurse Aide #1 admitted to pushing the resident and was suspended pending termination.
Findings
The facility substantiated the abuse allegation after an internal investigation confirmed that Certified Nurse Aide #1 pushed Resident #1 causing the resident to stumble backwards without falling. The Certified Nurse Aide was suspended and is expected to be terminated. The facility is educating staff on abuse and rough handling of residents.
Deficiencies (1)
10NYCRR 415.4(b) Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect. The facility failed to ensure residents were free from abuse when Certified Nurse Aide #1 pushed Resident #1 causing the resident to stumble backwards.
Report Facts
Residents Affected: 1
Date of incident: Mar 5, 2025
Date of internal investigation: Mar 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Named in abuse finding for pushing Resident #1. |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | Witnessed the abuse incident and conducted initial assessment. |
| Director of Nursing | Director of Nursing | Oversaw investigation and planned termination of Certified Nurse Aide #1. |
| Administrator | Administrator | Provided administrative oversight and confirmed lack of video footage. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 34
Date: Jan 30, 2025
Visit Reason
Multiple standard health and life safety code citations including a Level 3 citation for free of accident hazards with actual harm and systemic quality of care issues; all corrected.
Findings
Multiple standard health and life safety code citations including a Level 3 citation for free of accident hazards with actual harm and systemic quality of care issues; all corrected.
Deficiencies (34)
Develop/implement comprehensive care plan
Dialysis
Encoding/transmitting resident assessments
Free of accident hazards/supervision/devices
Infection prevention & control
Notice of bed hold policy before/upon transfer
Notice requirements before transfer/discharge
Nurse aide peform review-12 hr/yr in-service
Nutrition/hydration status maintenance
Personal privacy/confidentiality of records
Posted nurse staffing information
Quality of care
Reporting of alleged violations
Required in-service training for nurse aides
Resident rights/exercise of rights
Sufficient nursing staff
Cooking facilities
Discharge from exits
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Exit signage
Fire alarm system - testing and maintenance
Fundamentals - building system categories
Hazardous areas - enclosure
Illumination of means of egress
Rubbish chutes, incinerators, and laundry chu
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Portable fire extinguishers
Sprinkler system - installation
Stairways and smokeproof enclosures
Gas equipment - cylinder and container storag
Horizontal sliding doors
Physical environment
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Jan 30, 2025
Visit Reason
The visit was a recertification survey conducted from 01/22/2025 through 01/30/2025 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity during feeding, timely submission of Minimum Data Set assessments, comprehensive care planning for hospice residents, accident prevention and supervision, nutrition and hydration management, dialysis care oversight, staffing adequacy, nurse aide performance evaluations, nurse staffing information posting, infection prevention and control, and nurse aide training.
Deficiencies (11)
F 0550: The facility failed to ensure residents had the right to a dignified dining experience, with staff observed standing over residents while feeding and referring to a resident as a feeder.
F 0640: The facility did not submit Minimum Data Set assessments within 14 days for 2 residents, delaying required reporting.
F 0656: The facility failed to develop and implement a comprehensive care plan for a hospice resident, with no documented care plan after hospice admission.
F 0689: The facility failed to provide adequate supervision and assistance to prevent accidents, resulting in actual harm including fractures and bruises for multiple residents due to improper transfers and falls.
F 0692: The facility did not ensure a resident on fluid restriction had documented evidence of fluid intake monitoring and the fluid restriction was not reflected on meal tickets.
F 0698: The facility failed to provide consistent assessment and oversight before, during, and after dialysis treatment for a resident, with inconsistent documentation and missing pre/post dialysis notes.
F 0725: The facility did not consistently provide adequate nursing staff to meet resident needs, with multiple documented shifts failing to meet minimum staffing requirements across units and shifts.
F 0730: The facility failed to complete annual performance reviews for nursing staff, missing reviews for 2 of 5 certified nurse aides.
F 0732: The facility did not post daily resident census and nurse staffing information in a prominent, readily accessible place for residents and visitors on multiple days.
F 0880: The facility failed to implement infection prevention and control practices, including lack of a current water management plan for Legionella and failure of environmental services staff to follow contact precautions for a resident with Clostridium difficile.
F 0947: The facility did not ensure certified nurse aides received the required 12 hours of annual in-service training, with 3 of 5 aides not meeting this requirement.
Report Facts
Falls: 7
Deficiencies cited: 11
Staffing shortages: 50
Fluid restriction: 960
Dialysis treatments: 15
In-service training hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #36 | Observed feeding Resident #165 while standing. | |
| Certified Nurse Aide #37 | Observed feeding Resident #72 while standing. | |
| Certified Nurse Assistant #17 | Referred to Resident #585 as a feeder during lunch. | |
| Certified Nurse Assistant #21 | Referred to Resident #585 as a feeder during lunch. | |
| Director of Nursing | Provided multiple interviews regarding deficiencies and staffing. | |
| Registered Nurse Supervisor #3 | Interviewed regarding hospice care plan and supervision. | |
| Certified Nurse Aide #24 | Used sit to stand device instead of mechanical lift causing injury to Resident #70. | |
| Certified Nurse Aide #31 | Provided care alone to Resident #207 requiring two-person assist. | |
| Certified Nurse Aide #32 | Assisted with mechanical lift transfer for Resident #207. | |
| Registered Dietician #1 | Interviewed regarding fluid restriction for Resident #163. | |
| Nurse Educator | Provided in-service training hours for certified nurse aides. | |
| Director of Human Resources | Interviewed regarding annual performance appraisals. | |
| Nurse Manager #27 | Interviewed regarding posting of daily staffing information. | |
| Environmental Service Worker #28 | Observed not following contact precautions for Resident #588. | |
| Director of Facilities and Lead Engineer | Interviewed regarding water management plan for Legionella. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including resident privacy violations, delayed reporting of injuries of unknown origin, failure to provide timely notification of transfers and bed hold policies, inadequate care and supervision leading to resident injuries, insufficient staffing levels, and lapses in infection prevention and control practices.
Deficiencies (8)
F 0583: The facility failed to maintain residents' privacy and confidentiality of medical records by attaching another resident's health information to Resident #535's discharge summary.
F 0609: The facility did not timely report injuries of unknown origin for Residents #110 and #186 to the state agency within the required 2-hour timeframe.
F 0623: The facility failed to provide written notification to Resident #127 and the Ombudsman regarding hospital transfer as required.
F 0625: The facility did not notify Resident #127 or their representative in writing of the facility bed hold policy upon hospital transfer.
F 0684: Resident #534 sustained a fall resulting in fractured ribs and scapula; staff failed to report and assess the fall timely, delaying treatment.
F 0689: The facility failed to provide adequate supervision and assistance to prevent accidents for Residents #534, #70, #207, and #65, resulting in injuries including fractures and bruises.
F 0725: The facility did not consistently meet minimum nursing and certified nurse assistant staffing requirements from December 2024 through January 2025.
F 0880: The facility failed to implement an effective infection prevention and control program, including lack of a current water management plan for Legionella and failure of environmental staff to follow contact precautions.
Report Facts
Falls with injury: 4
Staffing shortages: 50
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #43 | Involved in failure to report Resident #534 fall and assisted in moving resident off floor without nurse assessment. | |
| Licensed Practical Nurse #44 | Aware of Resident #534 fall but did not notify supervisor or assess resident. | |
| Director of Nursing | Provided multiple interviews regarding delayed reporting, staffing shortages, and care deficiencies. | |
| Medical Doctor #46 | Primary Physician | Commented on Resident #534 fall and expected nurse assessment. |
| Medical Doctor #47 | Attending Physician | Commented on Resident #534 fall and pain management. |
| Certified Nurse Aide #24 | Used incorrect transfer device causing injury to Resident #70. | |
| Licensed Practical Nurse #25 | Received report of Resident #70 injury but did not document incident or notify supervisor timely. | |
| Certified Nurse Aide #31 | Provided care alone to Resident #207 requiring two-person assist, resulting in injury. | |
| Certified Nurse Aide #32 | Assisted Certified Nurse Aide #31 and reported injury to Resident #207. | |
| Environmental Service Worker #28 | Failed to don PPE and perform hand hygiene when entering contact isolation room. | |
| Director of Facilities | Lead Engineer | Unaware of responsibility for water management plan and risk assessment for Legionella. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jan 6, 2025
Visit Reason
Two Level 2 standard health citations for free from abuse and neglect and reporting of alleged violations, both isolated and corrected.
Findings
Two Level 2 standard health citations for free from abuse and neglect and reporting of alleged violations, both isolated and corrected.
Deficiencies (2)
Free from abuse and neglect
Reporting of alleged violations
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jan 6, 2025
Visit Reason
The inspection was conducted as an abbreviated survey focusing on allegations of abuse and failure to timely report suspected abuse at the Sarah Neuman Center for Rehabilitation and Nursing.
Findings
The facility failed to protect residents from abuse, specifically an incident where a Certified Nursing Assistant threw towels at a resident and yelled at them. Additionally, the facility did not timely report suspected abuse incidents to the New York State Department of Health as required.
Deficiencies (2)
F 0600: The facility did not ensure residents' rights to be free from abuse. Certified Nursing Assistant #4 threw towels at Resident #7 and yelled at them. The assistant was removed from caring for Resident #7 but continued caring for others during the shift. The Licensed Practical Nurse did not report the incident to their supervisor.
F 0609: The facility failed to timely report suspected abuse to proper authorities. Incidents involving Resident #1 and Resident #7 were not reported within 2 hours as required, with delays of up to two days.
Report Facts
Residents reviewed for abuse: 8
Residents affected: 2
Incident report submission delay: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Named in abuse incident involving throwing towels at Resident #7. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Did not immediately report alleged abuse by Certified Nursing Assistant #4 and finished their shift. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Failed to check injury and notify supervisor regarding Resident #1's skin injury. |
| Director of Nursing | Director of Nursing | Conducted investigation and suspended Certified Nursing Assistant #4. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jul 12, 2024
Visit Reason
Two Level 2 standard health citations for free from abuse and neglect and requirements before submitting a request, both isolated and corrected.
Findings
Two Level 2 standard health citations for free from abuse and neglect and requirements before submitting a request, both isolated and corrected.
Deficiencies (2)
Free from abuse and neglect
Requirements before submitting a request for
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 12, 2024
Visit Reason
The visit was an abbreviated survey conducted to investigate allegations of abuse involving a Certified Nurse Aide and a resident at the Sarah Neuman Center for Rehabilitation and Nursing.
Findings
The facility failed to ensure a resident's right to be free from abuse when a Certified Nurse Aide was observed aggressively grabbing a resident's arm. The Certified Nurse Aide was suspended pending investigation. The Director of Nursing found that the incident should have been reported immediately and that the Certified Nurse Aide should have been removed from the assignment pending investigation.
Deficiencies (1)
F 0600: Protect each resident from all types of abuse including physical, mental, sexual abuse, physical punishment, and neglect. The facility failed to prevent abuse when a Certified Nurse Aide aggressively grabbed Resident #1's arm during transport in the dayroom.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | Named in abuse allegation for aggressively grabbing Resident #1. | |
| Therapeutic Recreational Specialist | Witnessed the abuse incident and reported it. | |
| Registered Nurse Supervisor #1 | Received reports about the incident and did not immediately report to Director of Nursing. | |
| Director of Nursing | Reviewed incident and stated Certified Nurse Aide #2 should have been removed pending investigation. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 9, 2024
Visit Reason
One Level 2 standard health citation for free of accident hazards/supervision/devices, isolated and corrected.
Findings
One Level 2 standard health citation for free of accident hazards/supervision/devices, isolated and corrected.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: May 9, 2024
Visit Reason
The abbreviated survey was conducted to assess compliance with safety and supervision requirements related to resident transfers using mechanical lifts.
Findings
The facility failed to ensure adequate supervision and assistance during resident transfers, resulting in Resident #4 being transferred alone by a Certified Nurse Assistant despite care plans requiring two-person assistance. Resident #4 hit their head on the Hoyer lift bar but sustained no injury. The staff member was retrained and suspended from working with the resident.
Deficiencies (1)
F 0689: The facility did not ensure residents received adequate supervision and assistance to prevent accidents. Resident #4 was transferred alone using a Hoyer lift requiring two-person assistance and hit their head on the lift bar.
Report Facts
Date of incident: Oct 18, 2023
Date of MDS assessment: Sep 27, 2023
Date of care plan initiation: Nov 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Transferred Resident #4 alone using Hoyer lift against care plan; suspended and retrained |
| Director of Nursing | Director of Nursing | Interviewed regarding staff expectations and retraining after incident |
| Administrator | Administrator | Interviewed regarding policy enforcement and zero tolerance for abuse and neglect |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 8, 2024
Visit Reason
One Level 2 standard health citation for reporting - national health safety network, widespread and not corrected.
Findings
One Level 2 standard health citation for reporting - national health safety network, widespread and not corrected.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Oct 3, 2022
Visit Reason
One Level 2 standard health citation for infection prevention & control, isolated and corrected.
Findings
One Level 2 standard health citation for infection prevention & control, isolated and corrected.
Deficiencies (1)
Infection prevention & control
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Jul 8, 2022
Visit Reason
Multiple Level 2 standard health citations including free of accident hazards, investigate/prevent/correct alleged violation, and quality of care, all isolated and corrected.
Findings
Multiple Level 2 standard health citations including free of accident hazards, investigate/prevent/correct alleged violation, and quality of care, all isolated and corrected.
Deficiencies (3)
Free of accident hazards/supervision/devices
Investigate/prevent/correct alleged violation
Quality of care
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 19
Date: Jun 6, 2022
Visit Reason
Multiple Level 2 standard life safety code citations including corridor doors, discharge from exits, electrical equipment, and others, mostly pattern or isolated scope, all corrected.
Findings
Multiple Level 2 standard life safety code citations including corridor doors, discharge from exits, electrical equipment, and others, mostly pattern or isolated scope, all corrected.
Deficiencies (19)
Corridor - doors
Discharge from exits
Electrical equipment - testing and maintenanc
Electrical systems - essential electric syste
Exit signage
Fire alarm system - testing and maintenance
Gas equipment - cylinder and container storag
Horizontal sliding doors
Hazardous areas - enclosure
Illumination of means of egress
Portable fire extinguishers
Sprinkler system - installation
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Subdivision of building spaces - smoke barrie
Subsistence needs for staff and patients
Fundamentals - building system categories
Rubbish chutes, incinerators, and laundry chu
Physical environment
Inspection Report
Deficiencies: 0
Date: Jun 6, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for a nursing home survey conducted by the Centers for Medicare & Medicaid Services.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Dec 8, 2021
Visit Reason
One Level 2 standard health citation for free of accident hazards/supervision/devices, isolated and corrected.
Findings
One Level 2 standard health citation for free of accident hazards/supervision/devices, isolated and corrected.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 19, 2018
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The survey identified multiple deficiencies including inadequate housekeeping and maintenance, incomplete care planning and resident participation, inappropriate pressure ulcer care, medication administration errors including a 5-day missed dose of Hydrocortisone for a resident with Addison's disease, and inaccurate medical record documentation.
Deficiencies (6)
F 0584: The facility did not provide housekeeping and maintenance services necessary to maintain a clean, comfortable, and homelike environment, including peeling paint, missing floorboards, holes in walls, exposed wires, soiled floors, and unsealed ceiling openings.
F 0657: The facility failed to ensure one resident was given the opportunity to participate in care plan development and did not revise care plans with measurable objectives and appropriate interventions for pain and accident prevention.
F 0686: Medication was administered for excessive duration without adequate indication for ongoing use to one resident during pressure ulcer treatment; topical antibacterial cream was applied to intact skin.
F 0755: The facility did not ensure medication orders were processed consistently and accurately; a medication for Addison's disease was unavailable and not administered for 5 consecutive days.
F 0760: Medication was administered with significant error for one resident; Hydrocortisone was not administered as ordered for 5 days due to failed order transmission and communication breakdowns.
F 0842: Medical records were not accurately documented; pressure ulcer treatments that were not performed were documented as done.
Report Facts
Days medication unavailable: 5
Pressure ulcer size: 2.5
Pressure ulcer size: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding pain management and medication administration errors for Resident #153 and #312 |
| RN #3 | Clinical Care Coordinator | Reviewed Medication Administration Record for May 2018 and confirmed missed Hydrocortisone doses |
| MD #1 | Attending Physician | Interviewed regarding medication administration procedures and adverse effects for Resident #312 |
| MD #2 | Medical Director | Interviewed regarding medication incident and actions to be taken when medication is unavailable |
| Pharmacy Director | Pharmacy Director | Interviewed regarding medication availability and order transmission issues |
| Unit Nurse Manager | Unit Nurse Manager | Observed wound care and noted inaccurate documentation of pressure ulcer treatments |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Involved in medication incident where Hydrocortisone was unavailable and did not notify MD or Nursing Supervisor timely |
| Nurse Practitioner (NP) | Nurse Practitioner | Clarified medication order during Hydrocortisone availability incident |
| Social Worker | Social Worker | Interviewed regarding care plan meeting attendance documentation |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan meeting attendance documentation |
| Plant Operations Director (POD) | Plant Operations Director | Interviewed regarding maintenance and repair issues in the facility |
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