Deficiencies (last 4 years)
Deficiencies (over 4 years)
14.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
309% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 12
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and other operational standards.
Findings
The facility was found deficient in multiple areas including failure to develop and implement baseline and comprehensive care plans timely, inadequate personal care and hygiene assistance, improper medication administration practices, failure to maintain infection control protocols, improper labeling and storage of medications, and deficiencies in food safety and call light system maintenance.
Deficiencies (12)
Failed to develop and implement a baseline care plan within 48 hours of admission for 3 of 5 residents reviewed.
Failed to develop and implement a comprehensive person-centered care plan with measurable objectives for 2 of 6 residents reviewed.
Failed to develop a comprehensive care plan within 7 days of the comprehensive assessment for 1 of 5 residents reviewed.
Failed to provide necessary assistance with activities of daily living, including nail care, for 1 of 6 residents reviewed.
Failed to provide appropriate care to maintain or improve range of motion and failed to ensure physician orders for bilateral palm guards for 1 of 6 residents reviewed.
Failed to provide appropriate perineal care after incontinent episode for 1 of 2 residents reviewed, risking urinary tract infections.
Failed to follow physician ordered water flushes between each medication administration via G-Tube for 1 of 4 residents reviewed.
Failed to ensure attending physician documented review and action on pharmacist's medication regimen review recommendations for 1 of 6 residents reviewed.
Failed to label insulin pens with open dates on 2 medication carts, risking diminished medication effectiveness.
Failed to store, prepare, and serve food in accordance with professional standards including unlabeled food items, unsealed frozen food, improper hand hygiene, failure to take food temperatures, and improper placement of serving utensils.
Failed to maintain an infection prevention and control program by not disinfecting blood pressure cuffs between residents for 3 of 5 residents reviewed.
Failed to ensure call light systems were adequately equipped and call lights were within reach for 3 of 23 residents reviewed.
Report Facts
Residents reviewed for baseline care planning: 5
Residents reviewed for comprehensive care planning: 6
Residents reviewed for ADL care: 6
Residents reviewed for range of motion care: 6
Residents reviewed for incontinence care: 2
Residents reviewed for feeding tube care: 4
Residents reviewed for medication regimen review: 6
Medication carts reviewed: 4
Residents reviewed for infection control: 5
Residents reviewed for call light system: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN I | Licensed Vocational Nurse | Named in failure to flush G-tube medications as ordered and insulin pen labeling |
| MA N | Medication Aide | Named in failure to disinfect blood pressure cuff between residents |
| RN A | Registered Nurse | Named in insulin pen labeling deficiency |
| DON | Director of Nursing | Named in multiple interviews regarding care plan deficiencies, medication management, infection control, and call light system |
| Dietary Manager | Named in food safety deficiencies including labeling, hand hygiene, and food temperature monitoring | |
| Maintenance Director | Named in call light system maintenance deficiencies | |
| MDS Coordinator | Named in care plan completion deficiencies | |
| Pharmacy Consultant | Named in medication regimen review process |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 13, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically reviewing compliance with infection control policies and procedures related to medication administration and syringe use for residents with feeding tubes.
Findings
The facility failed to establish and maintain an effective infection prevention and control program, including failure to provide a written infection control policy. Specific deficiencies included improper hygiene and syringe use by nursing staff, such as using a syringe that had fallen on the ground and reusing syringes beyond the 24-hour recommended timeframe, placing residents at risk for infection.
Deficiencies (3)
Failure to perform proper hygiene during medication administration; use of a syringe with a plunger seal that had fallen on the ground.
Failure to perform proper syringe protocol by using a syringe beyond the 24-hour usage period for medication administration, flushing, and placement check.
Failure to provide evidence of a written Infection Control Policy.
Report Facts
Residents reviewed for infection control: 4
Date of observation video: Mar 11, 2025
Date of photograph: Mar 10, 2025
Medication administration observation time: 1310
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in findings for improper syringe use and infection control breaches |
| DON C | Director of Nursing | Interviewed regarding staff training and infection control policy provision |
| ADON E | Assistant Director of Nursing | Interviewed regarding staff training and syringe protocol |
| LVN F | Licensed Vocational Nurse | Interviewed regarding infection control training and syringe protocol |
| LVN G | Licensed Vocational Nurse | Interviewed regarding infection control training and syringe protocol |
| Medication Aide H | Medication Aide | Interviewed regarding infection control training and medication passing procedures |
| Physician D | Physician | Interviewed regarding infection risk related to syringe contamination and reuse |
| Administrator B | Administrator | Interviewed regarding provision of infection control policy |
Inspection Report
Routine
Deficiencies: 8
Date: Jul 24, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, activities of daily living, catheter and incontinence care, respiratory care, pharmaceutical services, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach for residents, incomplete and non-person-centered care plans, inadequate ADL care such as nail trimming, improper catheter and incontinence care, failure to maintain sterile technique during tracheostomy care, incomplete narcotic counts and signatures, food safety violations including expired and unlabeled food, and lapses in infection prevention practices such as hand hygiene and equipment disinfection.
Deficiencies (8)
Failure to ensure call lights were within reach for residents #18, #25, and #323.
Failure to develop and implement a comprehensive person-centered care plan for Resident #50, including addressing resistance to care and eating.
Failure to provide adequate ADL care, including failure to trim Resident #57's fingernails.
Failure to maintain catheter drainage bag below bladder during mechanical lift transfer for Resident #5, failure to provide timely incontinence care for Resident #44, and failure to keep catheter bag off the floor during transfer of Resident #176.
Failure to maintain sterile technique and keep dominant hand sterile during tracheostomy care and suctioning for Resident #44.
Failure to count and sign narcotic sheets at shift changes for Med Aide cart hall 500.
Failure to discard expired food, label and date food items, and cover hard-boiled eggs in the kitchen refrigerator.
Failure to disinfect blood pressure cuffs between residents, failure to perform hand hygiene during incontinence care, and failure to perform hand hygiene after mechanical lift transfer and catheter care.
Report Facts
Narcotic count sheet missing signatures: 10
Urine volume in catheter bag: 200
Length of Resident #57's fingernails: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN O | Charge Nurse | Named in call light deficiency findings for Residents #18, #25, and #323. |
| CNA N | Lead CNA | Named in call light deficiency findings for Residents #18, #25, and #323 and Resident #50 care plan findings. |
| LVN I | Charge Nurse | Named in incontinence care and tracheostomy care deficiencies for Resident #44. |
| LVN S | Nurse | Named in narcotic count sheet deficiency. |
| LVN R | Nurse | Named in narcotic count sheet deficiency. |
| MA L | Medication Aide | Named in infection control deficiency for failure to disinfect blood pressure cuffs. |
| MA M | Medication Aide | Named in infection control deficiency for failure to disinfect blood pressure cuffs. |
| CNA K | Certified Nursing Assistant | Named in infection control deficiency for failure to perform hand hygiene during incontinence care. |
| Staffing Coordinator | Named in catheter care and infection control deficiencies. | |
| LVN I | Licensed Vocational Nurse | Named in tracheostomy care deficiency. |
| Dietary Manager | Named in food safety deficiencies. |
Inspection Report
Routine
Deficiencies: 10
Date: Jul 24, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, activities of daily living, catheter and incontinence care, respiratory care, pharmaceutical services, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach for residents, incomplete and non-person-centered care plans, inadequate nail care, improper catheter and incontinence care, failure to maintain sterile technique during tracheostomy care, incomplete narcotic counts and signatures, improper food storage and labeling, and lapses in infection prevention practices such as hand hygiene and equipment disinfection.
Deficiencies (10)
Failed to ensure call lights were within reach for 3 residents, increasing risk for falls and unmet needs.
Failed to develop and implement a comprehensive, person-centered care plan for Resident #50, including addressing resistance to care and eating.
Failed to provide adequate nail care for Resident #57, resulting in long, chipped fingernails.
Failed to maintain catheter drainage bag below bladder during mechanical lift transfer for Resident #5.
Failed to provide timely and appropriate incontinence care for Resident #44.
Failed to keep catheter drainage bag off the floor during transfer of Resident #176.
Failed to maintain sterile technique and keep dominant hand sterile during tracheostomy care and suctioning for Resident #44.
Failed to count and sign narcotic sheets at shift changes for Med Aide cart hall 500.
Failed to discard expired food, label and date food items, and cover hard-boiled eggs properly in the kitchen.
Failed to disinfect blood pressure cuffs between residents, perform hand hygiene during incontinence care, and perform hand hygiene after mechanical lift transfer.
Report Facts
Narcotic count sheet missing signatures: 10
Urine volume in catheter drainage bag: 200
Length of Resident #57's fingernails: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN O | Charge Nurse | Named in call light deficiency findings for Residents #18, #25, and #323. |
| CNA N | Lead CNA | Named in call light deficiency findings for Residents #18, #25, and #323. |
| DON | Director of Nursing | Provided expectations on call light placement, nail care, narcotic counts, and infection control. |
| LVN I | Charge Nurse | Named in incontinence care and tracheostomy care deficiencies for Resident #44. |
| CNA K | Certified Nursing Assistant | Named in incontinence care and infection control deficiencies for Resident #176. |
| LVN S | Licensed Vocational Nurse | Named in narcotic count deficiencies. |
| LVN R | Licensed Vocational Nurse | Named in narcotic count deficiencies. |
| MA L | Medication Aide | Named in infection control deficiencies related to blood pressure cuff sanitation. |
| MA M | Medication Aide | Named in infection control deficiencies related to blood pressure cuff sanitation. |
| Staffing Coordinator | Named in catheter care and infection control deficiencies. | |
| Therapist | Named in catheter care deficiencies. | |
| LVN I | Licensed Vocational Nurse | Named in tracheostomy care deficiencies. |
| Dietary Manager | Named in food safety deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 9, 2024
Visit Reason
The inspection was conducted due to a complaint alleging neglect and abuse related to Resident #1 not receiving incontinent care and ADL assistance for over 13 hours during the night shift of 12/31/23 to 1/1/24.
Complaint Details
The complaint alleged neglect and abuse of Resident #1 due to failure to provide incontinent care and ADL assistance for over 13 hours during the night shift of 12/31/23 to 1/1/24. Family members observed neglect via room camera and reported concerns to facility staff. The facility failed to report the neglect timely to the abuse coordinator. Multiple staff interviews confirmed the neglect and failure to report.
Findings
The facility failed to protect Resident #1 from neglect and abuse by not providing incontinent care or repositioning for over 13 hours. CNA A refused to provide care on the night shift, and staff failed to report the neglect timely. Family members observed the neglect via room camera. The facility also failed to maintain proper infection control practices for Resident #1 and Resident #3.
Deficiencies (5)
Failure to provide incontinent care and repositioning to Resident #1 for over 13 hours on 12/31/23 to 1/1/24.
Failure to implement written policies and procedures to prevent abuse and neglect, resulting in deprivation of goods abuse for Resident #1.
Failure to timely report suspected neglect of Resident #1 to the abuse coordinator.
Failure to provide necessary ADL assistance and incontinent care to Resident #1, resulting in poor hygiene and distress.
Failure to maintain infection control practices including improper PPE use by staff and failure to perform hand hygiene during incontinent care for Residents #1 and #3.
Report Facts
Duration of neglect: 13
Number of residents reviewed for abuse: 10
Number of residents reviewed for neglect: 10
Number of CNA's scheduled on 12/31/23 night shift: 4
Number of times incontinent care documented: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Assigned to Resident #1 on night shift 12/31/23; failed to provide care and did not communicate decision to charge nurse; suspended pending investigation |
| LVN C | Licensed Vocational Nurse, Charge Nurse | Charge nurse on night shift 12/31/23; assigned Resident #1 to CNA A; did not verify ADL care provided; planned to report neglect but delayed |
| LVN D | Licensed Vocational Nurse | Morning nurse on 1/1/24; provided G-tube care but did not reposition or provide incontinent care; did not report neglect allegation immediately |
| CNA B | Certified Nursing Assistant | Morning CNA on 1/1/24; provided incontinent care and repositioning to Resident #1; aware of neglect allegation but did not report immediately |
| Staffing Coordinator | Licensed Vocational Nurse | Assisted with incontinent care on 1/1/24; aware of neglect allegation but did not report immediately; responsible for scheduling CNAs |
| ADON B | Assistant Director of Nursing | On-call nurse manager for 12/30/23-1/1/24; aware of neglect allegation; did not report immediately; assisted with incontinent care without proper hand hygiene |
| CNA E | Certified Nursing Assistant | Reported not working night shift 12/31/23; aware of Resident #1 care needs and neglect definition |
| CNA F | Certified Nursing Assistant | Worked night shift 12/31/23 on different unit; aware of Resident #1 care needs and neglect definition |
| CNA G | Certified Nursing Assistant | Worked night shift 12/31/23 on different unit; previously cared for Resident #1; aware of neglect definition |
| CNA O | Certified Nursing Assistant | Observed providing incontinent care to Resident #1 without proper hand hygiene; forgot to perform hand hygiene between glove changes |
| MA BB | Medical Assistant | Observed entering Resident #3 isolation room with improper mask use; wore surgical mask under N95 with strap hanging down; lacked face shield or goggles |
| DON | Director of Nursing | Responsible for abuse coordinator backup; aware of neglect allegations; stated expectations for ADL care and reporting; confirmed staff training on abuse and neglect |
| Facility Administrator | Abuse Coordinator | Investigating neglect allegation; suspended CNA A; reported incident to TX HHS within 2 hours of notification |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 28, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to establish and implement policies addressing resident admission, specifically the lack of a signed admission agreement for Resident #1.
Complaint Details
The complaint investigation found that Resident #1 was not provided a signed admission agreement or information upon admission, and the facility did not have a policy for admission paperwork completion. The admission Coordinator and Administrator confirmed the paperwork was not completed and the family was unaware of the facility's policies and services.
Findings
The facility failed to provide a signed admission agreement or information upon admission for Resident #1, who was discharged without such documentation. The admission MDS assessment was incomplete, and the facility lacked a policy on completing admission paperwork. Interviews confirmed the admission paperwork was not completed and the family was unaware of the facility's services and policies.
Deficiencies (1)
Failure to require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and failure to inform residents what care they do not provide, specifically the lack of a signed admission agreement for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admission Coordinator | Responsible for completing admission agreements; confirmed no admission paperwork or agreements for Resident #1. | |
| Administrator | Stated responsibility of Admission Coordinator to complete paperwork within 2-3 days; confirmed no policy on admission paperwork completion. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 5, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to protect the confidentiality of resident health information and failure to maintain a sanitary, safe, and comfortable environment in certain resident rooms.
Complaint Details
The complaint investigation found substantiated issues related to privacy violations and unsanitary conditions in resident rooms.
Findings
The facility failed to ensure confidentiality of Resident #1's personal health information during medication pass when a laptop was left unlocked, and failed to maintain cleanliness in two resident rooms, with substances on floors and used medical supplies left out, placing residents at risk of privacy violations and unsafe living conditions.
Deficiencies (2)
Failed to protect the confidentiality of personal health care information by leaving a medication cart laptop unlocked during medication pass.
Failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior in two resident rooms, including presence of red sticky substance, crumbs, thick white substance, and used medical supplies.
Report Facts
Residents reviewed for confidentiality: 3
Bedrooms reviewed for environment: 5
Housekeeping staff: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in deficiency for leaving medication cart laptop unlocked |
| Director of Nursing | Interviewed regarding policy on locking computer screens during medication pass | |
| Housekeeping Supervisor | Interviewed regarding housekeeping staffing and cleaning practices |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: May 20, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident rights, notification of changes, care planning, physician orders, weight loss interventions, respiratory care, and infection control at the nursing facility.
Complaint Details
The complaint investigation revealed multiple failures including resident rights violations, failure to notify physicians of significant changes, inadequate care planning, failure to follow physician orders for oxygen and enteral feeding, failure to provide appropriate respiratory and tracheostomy care, and infection control breaches. Immediate Jeopardy was identified related to nutrition and feeding practices but was removed after the facility implemented a Plan of Removal.
Findings
The facility failed to ensure residents' participation in care planning, timely notification of significant changes to physicians, proper care planning for weight loss and oxygen therapy, administration of enteral feedings as ordered, appropriate respiratory and tracheostomy care, and infection control practices. Significant weight loss was noted in residents with inadequate interventions and communication. Immediate Jeopardy was identified related to nutrition and feeding practices but was removed after corrective actions.
Deficiencies (9)
Failed to allow resident to participate in the development and implementation of person-centered plan of care.
Failed to notify resident's physician and responsible party of significant changes in condition for two residents with weight loss.
Failed to have physician orders for resident's oxygen use upon admission.
Failed to develop and implement comprehensive person-centered care plans for residents with significant weight loss and oxygen therapy needs.
Failed to provide necessary services for residents unable to perform activities of daily living, including nail care and skin care.
Failed to ensure residents maintained acceptable nutritional status and implement significant weight loss interventions, resulting in Immediate Jeopardy.
Failed to ensure enteral feeding physician orders were followed for a resident with a feeding tube, resulting in Immediate Jeopardy.
Failed to maintain an infection control program and ensure proper hand hygiene during incontinent care.
Failed to provide safe and appropriate respiratory care including sterile tracheostomy care.
Report Facts
Weight loss percentage: 7.85
Weight loss percentage: 12
Weight loss percentage: 20.8
Weight loss percentage: 23
Tube feeding rate: 85
Tube feeding rate: 60
Tube feeding volume: 2008
Tube feeding volume: 1740
Tube feeding volume: 250
Tube feeding frequency: 3
Oxygen flow rate: 3
Nail length: 0.3
Nail length: 0.4
Nail length: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN G | Licensed Vocational Nurse | Named in failure to administer enteral feedings and lack of awareness of significant weight loss for Resident #58 |
| LVN I | Licensed Vocational Nurse | Named in failure to administer enteral feedings and failure to document feeding pump use for Resident #58 |
| Agency LVN F | Agency Licensed Vocational Nurse | Named in failure to administer enteral feedings and lack of training on PEG feedings |
| MDS Coordinator C | MDS Coordinator | Named in failure to ensure resident participation in care planning |
| Social Worker | Social Worker | Named in failure to schedule care plan conferences with resident participation |
| DON | Director of Nursing | Named in failure to ensure care plan conferences, weight monitoring, and oxygen order follow-up |
| Dietitian | Dietitian | Named in failure to communicate significant weight loss and implement nutrition interventions |
| LVN D | Licensed Vocational Nurse | Named in failure to maintain sterile technique during tracheostomy care |
| CNA N | Certified Nursing Assistant | Named in failure to perform hand hygiene during incontinent care |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 15, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate treatment and care according to physician orders and the resident's care plan, specifically concerning wound care for Resident #4.
Complaint Details
The complaint investigation found that the facility did not implement a wound vac for Resident #4 as ordered starting 5/10/2023, with the wound vac not initiated until the afternoon of 5/12/2023. Interviews with the Director of Nursing (DON) and other staff confirmed lack of awareness and absence of policy regarding implementation of physician orders.
Findings
The facility failed to follow Resident #4's treatment orders and care plan to ensure that previously identified wounds did not worsen, including failure to apply a prescribed wound vac in a timely manner. This failure posed risks of infection, delayed healing, pain, and diminished quality of life.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically not applying wound vac as ordered for Resident #4.
Report Facts
Date of wound vac order: May 10, 2023
Date wound vac initiated: May 12, 2023
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding wound care orders and facility policy | |
| OPCRN | Interviewed regarding receipt and initiation of wound care orders | |
| FWCN | Entered physician's order and documented wound culture |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 5, 2023
Visit Reason
Annual survey inspection of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 24, 2022
Visit Reason
The inspection was conducted due to complaints regarding failure to implement timely interventions for a resident's left hand contracture, inadequate supervision and assistance devices to prevent accidents, failure to follow therapeutic diets, and infection prevention and control deficiencies.
Complaint Details
The complaint investigation focused on allegations of failure to provide timely care planning and therapy for a resident's contracture, unsafe resident transfers, improper diet preparation and serving, and lapses in infection control practices.
Findings
The facility failed to timely update and implement care plans for a resident's left hand contracture, resulting in pain and decreased mobility. There were unsafe transfer practices and malfunctioning wheelchairs and mechanical lifts. The facility did not consistently serve prescribed therapeutic diets and failed to follow infection control protocols including sanitizing equipment and hand hygiene.
Deficiencies (6)
Failure to develop and implement a complete care plan for Resident #69's left hand contracture with timely interventions and therapy referral.
Failure to provide appropriate care to maintain or improve range of motion for Resident #69, resulting in actual harm due to pain and contracture progression.
Failure to ensure adequate supervision and safe transfer techniques, including failure to use gait belts and malfunctioning wheelchairs and mechanical lifts affecting Residents #13 and #69.
Failure to ensure menus were followed and residents on regular diets were served correct measured food portions.
Failure to provide food prepared in a form designed to meet individual needs for Residents #12 and #27 by not serving mechanical soft diets as ordered.
Failure to maintain an infection prevention and control program, including failure to sanitize blood pressure cuffs between residents and failure to perform hand hygiene during colostomy care.
Report Facts
Residents reviewed for comprehensive care plans: 18
Residents reviewed for limited ROM: 19
Residents reviewed for accident hazards/supervision/devices: 3
Residents reviewed for therapeutic diets: 23
Residents observed for infection control: 10
Pain rating: 9
Age of lifts: 9
Date of survey completion: Mar 24, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN F | Licensed Vocational Nurse | Reported Resident #69's contracture to ADON B and noted failure to refer to therapy |
| ADON B | Assistant Director of Nursing | Aware of Resident #69's contracture but failed to notify DOR or care plan |
| RN C | Registered Nurse | Aware of contracture, assumed therapy was involved, failed hand hygiene during colostomy care |
| CNA D | Certified Nursing Assistant | Involved in unsafe transfer of Resident #13 and Resident #69, unaware of therapy for contracture |
| CNA E | Certified Nursing Assistant | Involved in unsafe transfer of Resident #13 and Resident #69, unaware of therapy for contracture |
| OT | Occupational Therapist | Assessed Resident #69's contracture and provided therapy plan |
| DON | Director of Nursing | Notified of contracture late, implemented plan of correction, stated expectation for gait belt use and hand hygiene |
| Administrator | Facility Administrator | Oversaw daily stand-up meetings, noted therapy screening process |
| MA A | Medication Aide | Failed to sanitize blood pressure cuff between residents |
| MDS Coordinator G | MDS Coordinator | Completed significant change assessment for Resident #69 |
| Speech Therapist | Speech Therapist | Provided therapy for Resident #69 and reported contracture concern |
| Maintenance Director | Maintenance Director | Addressed wheelchair and mechanical lift issues |
| Resident #69's Physician | Physician | Relied on therapy to address contracture concerns |
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