On June 28, 2023 a
Exhibit,Appendix
was filed
involving a dispute between
People Of The State Of New York, By Letitia James, Attorney General Of The State Of New York,
and
Abraham Operations Associates Llc Dba Beth Abraham Center For Rehabilitation And Nursing,
Aharon Lantzitsky,
Amir Abramchik,
Aron Gittleson,
Beth Rozenberg,
Bis Funding Capital Llc,
Centers For Care Llc Dba Centers Health Care,
Cfsc Downstate Llc,
Daryl Hagler,
David Greenberg,
Delaware Operations Associates Llc Dba Buffalo Center For Rehabilitation And Nursing,
Delaware Real Property Associates Llc,
Elliot Kahan,
Hollis Operating Co Llc Dba Holliswood Center For Rehabilitation And Healthcare,
Hollis Real Estate Co Llc,
Jeffrey Sicklick,
Jonathan Hagler,
Kenneth Rozenberg,
Leo Lerner,
Light Property Holdings Ii Associates Llc,
Mordechai Moti Hellman,
Reuven Kaufman,
Schnur Operations Associates Llc Dba Martine Center For Rehabilitation And Nursing,
Skilled Staffing Llc,
Sol Blumenfeld,
for Commercial - Other - Commercial Division
in the District Court of New York County.
Preview
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF: 07/09/2023
Exhibit G
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF:
PRINTED:07/09/2023
07/04/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335424 09/20/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
12 TIBBITS AVENUE
MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
F 000 INITIAL COMMENTS F 000
An Abbreviated Survey (NY00281439) was
conducted at Martine Center for Rehabilitation
and Nursing to determine compliance with 42
CFR Part 483 requirements for Long Term Care
Facilities. Deficiencies were not cited as a result
of this survey.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Electronically Signed 11/02/2022
Any Deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide
sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of the survey whether or not a
plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the
facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and
signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EXY811 Facility ID: 1059
If continuation sheet Page 1 of 1
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF: 07/09/2023
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF:
PRINTED:07/09/2023
07/04/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335424 02/03/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
12 TIBBITS AVENUE
MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
F 000 INITIAL COMMENTS F 000
On February 3, 2021, a Focused Infection
Control COVID-19 survey (FICS) was completed
at Martine Center for Rehab to determine if this
facility was in compliance with State and Federal
requirements related to proper infection
prevention and control practices to prevent the
development and transmission of COVID-19.
The facility was in substantial compliance with
participation requirements and no deficiencies
were cited.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Electronically Signed 02/05/2021
Any Deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide
sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of the survey whether or not a
plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the
facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and
signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VFZ111 Facility ID: 1059
If continuation sheet Page 1 of 1
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF: 07/09/2023
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF:
PRINTED:07/09/2023
07/04/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335424 03/08/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
12 TIBBITS AVENUE
MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
F 000 INITIAL COMMENTS F 000
On March 8, 2021 a Focused Infection Control
COVID-19 survey (FICS) was completed at
Martine Center for Rehab to determine if this
facility was in compliance with State and Federal
requirements related to proper infection
prevention and control practices to prevent the
development and transmission of COVID-19.
The facility was in substantial compliance with
participation requirements and no deficiencies
were cited.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Electronically Signed 03/17/2021
Any Deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide
sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of the survey whether or not a
plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the
facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and
signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KEYS11 Facility ID: 1059
If continuation sheet Page 1 of 1
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF: 07/09/2023
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF:
PRINTED:07/09/2023
07/04/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335424 05/06/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
12 TIBBITS AVENUE
MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
F 000 INITIAL COMMENTS F 000
On May 6, 2020, a Focused Infection Control
COVID-19 survey # NY00256338 was
completed to determine if this facility was in
compliance with state and Federal requirements
related to proper infection prevention and
control practices to prevent the development
and transmission of COVID-19. The facility is in
compliance with participation requirements and
no deficiencies were cited.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Electronically Signed 07/12/2020
Any Deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide
sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of the survey whether or not a
plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the
facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and
signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8W6P11 Facility ID: 1059
If continuation sheet Page 1 of 1
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF: 07/09/2023
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF:
PRINTED:07/09/2023
07/04/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335424 05/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
12 TIBBITS AVENUE
MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
F 000 INITIAL COMMENTS F 000
An Abbreviated Surevy was conducted at
Martine Center for Rehab & Nursing to
determine compliance with 42 CFR Part 483
Requirements for Long Term Care Facilities.
The following deficiencies were cited as a result
of this survey:
42 CFR 483.12(c)(1)(4)-Reporting of Alleged
Viloations
42 CFR 483.20(g)-Accuracy of Assessments
F 609 483.12(c)(1)(4) Reporting of Alleged Violations F 609 1. 06/17/2022
SS=D
§483.12(c) In response to allegations of abuse, • Involved resident expired in the
neglect, exploitation, or mistreatment, the facility facility on 1/18/22.
must: • Resident’s Family were notified of
the expiration by Facility NP & SW.
§483.12(c)(1) Ensure that all alleged violations • The Administrator and Director of
involving abuse, neglect, exploitation or Nursing reviewed Facility Policy on Abuse
mistreatment, including injuries of unknown Prohibition and Accident and Incident
source and misappropriation of resident Policy; No changes were necessary at this
property, are reported immediately, but not later time.
than 2 hours after the allegation is made, if the
events that cause the allegation involve abuse 2.
or result in serious bodily injury, or not later than
24 hours if the events that cause the allegation We acknowledge that all residents in the
do not involve abuse and do not result in serious facility have the potential to be affected by
bodily injury, to the administrator of the facility this deficient practice.
and to other officials (including to the State
Survey Agency and adult protective services • A List of residents who expired in
where state law provides for jurisdiction in long- the Last 3 months post incidents of fall or
term care facilities) in accordance with State law deaths related to other accidents/incidents
through established procedures. was compiled and reviewed to determine if
such deaths were reported to DOH and
§483.12(c)(4) Report the results of all other relevant State Agencies per DOH
investigations to the administrator or his or her guideline and facility Policy. No other
designated representative and to other officials related incident was identified.
in accordance with State law, including to the
State Survey Agency, within 5 working days of 3.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Electronically Signed 06/28/2022
Any Deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide
sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of the survey whether or not a
plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the
facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and
signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWG911 Facility ID: 1059
If continuation sheet Page 1 of 9
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF:
PRINTED: 07/09/2023
07/04/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING
335424 05/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
12 TIBBITS AVENUE
MARTINE CENTER FOR REHABILITATION AND NURSING
WHITE PLAINS, NY 10606
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFlX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFlX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
F 609 Continued From page 1 F 609
the incident, and if the alleged violation is
verified appropriate corrective action must be " AII employees will be in-serviced
taken. by DNS or designee will provide Inservice
and education on abuse prohibition and
This REQUIREMENT is not met as evidenced incident policy.
reporting
by: " Reportable incidents and will do
so within DOH guidelines as applicable.
Based on record review, observation and " will maintain
Facility
interviews conducted during an Abbreviated Accident/Incident and will be reviewed
Log
Survey (NY00296336), the facility did not ensure and reported at QA
weekly monthly
that an incident was reported to the State x6 months
meeting
Survey Agency in accordance with State law.
Specifically, Resident #1 was found 4.
unresponsive in the bathroom and passed away
after failed (Cardiopulmonary Resuscitation) Facility Incident/Accident Report will be
CPR attempts by staff andEmergency Medical submitted to Monthly QA for review to
Services (EMS). The facility did not report the determine if Reportable guidelines were
incident to the New York State Department of followed x6 months
Health (NYSDOH) after the coroner report
indicated that the cause of death was by DNS/Administrator will conduct Monthly
asphyxiation-choking on steak. The death was audit on all resident expirations to
also not reported to the Health Electronic determine if any death that occurred post
Response Data System (HERDS). fall/Accident/Incident were reported per
DOH Guidelines. Findings will
The findings are: be presented QAPI committee monthly x6
months.
The facility Policy and Procedure titled "Accident
/Incident"
dated 11/2013, revised 2/2022 5.
documented that the purpose of the policy is to Date of Correction: 6/17/2022
monitor and evaluate all occurrences of Responsible parties: Administrator, DNS
accidents or incidents or adverse events
occurring on the facility's premises which is not
consistent with the routine operation of the
facility or care of a particular resident. These
occurrences must be evaluated and
investigated. The policy specified that the "DON
and Administrator are responsible to review
Incident / Investigation and Conclusions to
determine if incident requires reporting to
etc."
outside agencies such as DOH, OIG CMS
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWG911 Facility ID: 1059 If continuation sheet Page 2 of 9
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF:
PRINTED: 07/09/2023
07/04/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING
335424 05/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
12 TIBBITS AVENUE
MARTINE CENTER FOR REHABILITATION AND NURSING
WHITE PLAINS, NY 10606
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFlX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFlX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
F 609 Continued From page 2 F 609
The State Agency (NYSDOH) Incident Reporting
Manual dated 8/2016 documented "at least one
of the following elements must be present for an
incident to be reportable to the NYS DOH:
Abuse, Neglect, death related to an accident
origin."
and/or injury of unknown
Resident was admitted to the facility on
07/27/2021 with diagnoses that included
Hypertension, Dysphagia and Anxiety Disorder.
The Quarterly Minimum Data Set (MDS, an
assessment tool) dated 12/03/2021,
documented that the resident had a BIMS (Brief
Interview for Mental Status used to determine
attention, orientation, and
ability to recall
information) score of 10/15, associated with
moderate cognition impairment. The MDS
documented that resident required extensive
one-person assistance for bed mobility, transfer;
walk in room and corridor, locomotion on and off
the unit; dressing, toilet use and personal
hygiene. The resident required supervision with
setup help only with eating.
Review of the Comprehensive Progress Notes
from 9/14/2021 to 1/18/2022 revealed no
documented evidence of the resident having any
issues with swallowing / diet / nutrition.
Review of the Social Work Note dated 1/19/2022
documented that the resident awaypassed on
1/18/2022 in the facility and the family was
notified by the Nurse Practitioner (NP) and
nursing staff. The resident was pronounced
dead by EMS.
Review of accident/incident (A/I) investigation
dated 1/18/2022 documented that the resident
found unresponsive on the floor of the bathroom,
CPR initiated but was unsuccessful and
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWG911 Facility ID: 1059 If continuation sheet Page 3 of 9
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023
NYSCEF DOC. NO. 716 RECEIVED NYSCEF:
PRINTED:07/09/2023
07/04/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
B. WING __________________________
335424 05/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
12 TIBBITS AVENUE
MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVID
Preview
FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: 07/09/2023 Exhibit G FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: PRINTED:07/09/2023 07/04/2023 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING __________________________ 335424 09/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12 TIBBITS AVENUE MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 000 INITIAL COMMENTS F 000 An Abbreviated Survey (NY00281439) was conducted at Martine Center for Rehabilitation and Nursing to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. Deficiencies were not cited as a result of this survey. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 11/02/2022 Any Deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of the survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: EXY811 Facility ID: 1059 If continuation sheet Page 1 of 1 FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: 07/09/2023 FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: PRINTED:07/09/2023 07/04/2023 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING __________________________ 335424 02/03/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12 TIBBITS AVENUE MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 000 INITIAL COMMENTS F 000 On February 3, 2021, a Focused Infection Control COVID-19 survey (FICS) was completed at Martine Center for Rehab to determine if this facility was in compliance with State and Federal requirements related to proper infection prevention and control practices to prevent the development and transmission of COVID-19. The facility was in substantial compliance with participation requirements and no deficiencies were cited. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 02/05/2021 Any Deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of the survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: VFZ111 Facility ID: 1059 If continuation sheet Page 1 of 1 FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: 07/09/2023 FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: PRINTED:07/09/2023 07/04/2023 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING __________________________ 335424 03/08/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12 TIBBITS AVENUE MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 000 INITIAL COMMENTS F 000 On March 8, 2021 a Focused Infection Control COVID-19 survey (FICS) was completed at Martine Center for Rehab to determine if this facility was in compliance with State and Federal requirements related to proper infection prevention and control practices to prevent the development and transmission of COVID-19. The facility was in substantial compliance with participation requirements and no deficiencies were cited. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 03/17/2021 Any Deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of the survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KEYS11 Facility ID: 1059 If continuation sheet Page 1 of 1 FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: 07/09/2023 FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: PRINTED:07/09/2023 07/04/2023 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING __________________________ 335424 05/06/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12 TIBBITS AVENUE MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 000 INITIAL COMMENTS F 000 On May 6, 2020, a Focused Infection Control COVID-19 survey # NY00256338 was completed to determine if this facility was in compliance with state and Federal requirements related to proper infection prevention and control practices to prevent the development and transmission of COVID-19. The facility is in compliance with participation requirements and no deficiencies were cited. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 07/12/2020 Any Deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of the survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8W6P11 Facility ID: 1059 If continuation sheet Page 1 of 1 FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: 07/09/2023 FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: PRINTED:07/09/2023 07/04/2023 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING __________________________ 335424 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12 TIBBITS AVENUE MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 000 INITIAL COMMENTS F 000 An Abbreviated Surevy was conducted at Martine Center for Rehab & Nursing to determine compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. The following deficiencies were cited as a result of this survey: 42 CFR 483.12(c)(1)(4)-Reporting of Alleged Viloations 42 CFR 483.20(g)-Accuracy of Assessments F 609 483.12(c)(1)(4) Reporting of Alleged Violations F 609 1. 06/17/2022 SS=D §483.12(c) In response to allegations of abuse, • Involved resident expired in the neglect, exploitation, or mistreatment, the facility facility on 1/18/22. must: • Resident’s Family were notified of the expiration by Facility NP & SW. §483.12(c)(1) Ensure that all alleged violations • The Administrator and Director of involving abuse, neglect, exploitation or Nursing reviewed Facility Policy on Abuse mistreatment, including injuries of unknown Prohibition and Accident and Incident source and misappropriation of resident Policy; No changes were necessary at this property, are reported immediately, but not later time. than 2 hours after the allegation is made, if the events that cause the allegation involve abuse 2. or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation We acknowledge that all residents in the do not involve abuse and do not result in serious facility have the potential to be affected by bodily injury, to the administrator of the facility this deficient practice. and to other officials (including to the State Survey Agency and adult protective services • A List of residents who expired in where state law provides for jurisdiction in long- the Last 3 months post incidents of fall or term care facilities) in accordance with State law deaths related to other accidents/incidents through established procedures. was compiled and reviewed to determine if such deaths were reported to DOH and §483.12(c)(4) Report the results of all other relevant State Agencies per DOH investigations to the administrator or his or her guideline and facility Policy. No other designated representative and to other officials related incident was identified. in accordance with State law, including to the State Survey Agency, within 5 working days of 3. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Electronically Signed 06/28/2022 Any Deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of the survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWG911 Facility ID: 1059 If continuation sheet Page 1 of 9 FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: PRINTED: 07/09/2023 07/04/2023 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING 335424 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12 TIBBITS AVENUE MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFlX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFlX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 609 Continued From page 1 F 609 the incident, and if the alleged violation is verified appropriate corrective action must be " AII employees will be in-serviced taken. by DNS or designee will provide Inservice and education on abuse prohibition and This REQUIREMENT is not met as evidenced incident policy. reporting by: " Reportable incidents and will do so within DOH guidelines as applicable. Based on record review, observation and " will maintain Facility interviews conducted during an Abbreviated Accident/Incident and will be reviewed Log Survey (NY00296336), the facility did not ensure and reported at QA weekly monthly that an incident was reported to the State x6 months meeting Survey Agency in accordance with State law. Specifically, Resident #1 was found 4. unresponsive in the bathroom and passed away after failed (Cardiopulmonary Resuscitation) Facility Incident/Accident Report will be CPR attempts by staff andEmergency Medical submitted to Monthly QA for review to Services (EMS). The facility did not report the determine if Reportable guidelines were incident to the New York State Department of followed x6 months Health (NYSDOH) after the coroner report indicated that the cause of death was by DNS/Administrator will conduct Monthly asphyxiation-choking on steak. The death was audit on all resident expirations to also not reported to the Health Electronic determine if any death that occurred post Response Data System (HERDS). fall/Accident/Incident were reported per DOH Guidelines. Findings will The findings are: be presented QAPI committee monthly x6 months. The facility Policy and Procedure titled "Accident /Incident" dated 11/2013, revised 2/2022 5. documented that the purpose of the policy is to Date of Correction: 6/17/2022 monitor and evaluate all occurrences of Responsible parties: Administrator, DNS accidents or incidents or adverse events occurring on the facility's premises which is not consistent with the routine operation of the facility or care of a particular resident. These occurrences must be evaluated and investigated. The policy specified that the "DON and Administrator are responsible to review Incident / Investigation and Conclusions to determine if incident requires reporting to etc." outside agencies such as DOH, OIG CMS FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWG911 Facility ID: 1059 If continuation sheet Page 2 of 9 FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: PRINTED: 07/09/2023 07/04/2023 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING 335424 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12 TIBBITS AVENUE MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFlX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFlX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) F 609 Continued From page 2 F 609 The State Agency (NYSDOH) Incident Reporting Manual dated 8/2016 documented "at least one of the following elements must be present for an incident to be reportable to the NYS DOH: Abuse, Neglect, death related to an accident origin." and/or injury of unknown Resident was admitted to the facility on 07/27/2021 with diagnoses that included Hypertension, Dysphagia and Anxiety Disorder. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 12/03/2021, documented that the resident had a BIMS (Brief Interview for Mental Status used to determine attention, orientation, and ability to recall information) score of 10/15, associated with moderate cognition impairment. The MDS documented that resident required extensive one-person assistance for bed mobility, transfer; walk in room and corridor, locomotion on and off the unit; dressing, toilet use and personal hygiene. The resident required supervision with setup help only with eating. Review of the Comprehensive Progress Notes from 9/14/2021 to 1/18/2022 revealed no documented evidence of the resident having any issues with swallowing / diet / nutrition. Review of the Social Work Note dated 1/19/2022 documented that the resident awaypassed on 1/18/2022 in the facility and the family was notified by the Nurse Practitioner (NP) and nursing staff. The resident was pronounced dead by EMS. Review of accident/incident (A/I) investigation dated 1/18/2022 documented that the resident found unresponsive on the floor of the bathroom, CPR initiated but was unsuccessful and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: KWG911 Facility ID: 1059 If continuation sheet Page 3 of 9 FILED: NEW YORK COUNTY CLERK 07/09/2023 05:25 PM INDEX NO. 451549/2023 NYSCEF DOC. NO. 716 RECEIVED NYSCEF: PRINTED:07/09/2023 07/04/2023 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING __________________________ 335424 05/26/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 12 TIBBITS AVENUE MARTINE CENTER FOR REHABILITATION AND NURSING WHITE PLAINS, NY 10606 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVID