Inspection Reports for Ascension Living Sacred Heart Village
515 N MAIN ST, IN, 46710
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Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Mar 21, 2025
Visit Reason
This visit was conducted to investigate Complaints IN00454807 and IN00454527.
Findings
No deficiencies related to the allegations in Complaints IN00454807 and IN00454527 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding these complaints.
Complaint Details
Complaint IN00454807 and Complaint IN00454527 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 9
Census Bed Type: 68
Census Bed Type: 77
Census Payor Type: 5
Census Payor Type: 63
Census Payor Type: 9
Census Payor Type: 77
Inspection Report
Re-Inspection
Census: 76
Capacity: 133
Deficiencies: 0
Mar 19, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/05/25 was performed by the Indiana Department of Health.
Findings
At this PSR survey, Ascension Living Sacred Heart Village was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and applicable state and national fire safety codes.
Report Facts
Facility capacity: 133
Census: 76
Inspection Report
Life Safety
Census: 76
Capacity: 133
Deficiencies: 7
Feb 5, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification (LSC) and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Multiple deficiencies were identified related to fire safety systems, corridor doors, electrical safety, trash receptacles, and oxygen storage ventilation.
Severity Breakdown
SS=E: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure staff were instructed in the use of the UL 300 hood system in the kitchen; staff did not know how to activate the fire suppression system. | SS=E |
| Failed to properly install and maintain equipment protected by kitchen hood extinguishing systems; flat top grill not fully under hood and suppression system. | SS=E |
| Pantries open to corridor lacked electrically supervised automatic smoke detection system. | SS=E |
| Therapy gym corridor doors lacked means to keep doors closed, no latching, and would not resist passage of smoke. | SS=E |
| Ground fault circuit interrupter (GFCI) in Saint Francis break room failed to trip and did not break electrical circuit. | SS=E |
| Trash receptacles in one corridor were not maintained properly; three 33-gallon barrels totaling 99 gallons placed within 64 square feet. | SS=E |
| Oxygen storage/transfer room lacked properly working mechanical ventilation; no air pull from vent to outside. | SS=E |
Report Facts
Certified beds: 133
Census: 76
Residents affected: 40
Residents affected: 20
Residents affected: 10
Residents affected: 20
Residents affected: 20
Trash barrels: 3
Trash capacity (gallons): 99
Pass-through window size: 45
Pass-through window size: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marie Wallace | Executive Director | Signed report as Laboratory Director's or Provider/Supplier Representative |
| Maintenance Director | Interviewed regarding deficiencies and observations | |
| Maintenance-Tech | Interviewed and observed during survey | |
| Dietary Manager | Responsible for staff education on kitchen hood system | |
| Dietary Staff Member | Interviewed about knowledge of fire suppression system |
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 21, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Ascension Living Sacred Heart Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 5
Dec 19, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey and the Investigation of Complaint IN00448890.
Findings
The facility was found to have deficiencies related to privacy of health information, ongoing assessment for change in condition, functional positioning, catheter care, and food safety and sanitation. The complaint investigation found no deficiencies related to the allegations. The facility was found in compliance with State Residential Licensure Survey requirements.
Complaint Details
Complaint IN00448890 was investigated during the visit; no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure privacy of health information for 2 of 18 residents; catheter bags were visible and staff communicated resident needs loudly in public areas. | SS=D |
| Failed to ensure ongoing assessment for a change in condition for 1 of 4 residents reviewed. | SS=D |
| Failed to ensure functional and comfortable positioning for 1 of 3 residents reviewed; resident's head was leaning forward and staff manually lifted head during feeding. | SS=D |
| Failed to ensure sanitary handling of a catheter bag in 1 of 2 residents reviewed; catheter bag was in contact with the floor. | SS=D |
| Failed to ensure safe, sanitary food storage and serving practices; issues included undated and expired food, unsealed whipped cream, moisture between pans, dirty mixer, improper glove use, and contaminated plastic wrap box. | SS=F |
Report Facts
Census: 96
Survey dates: 5
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marie Wallace | Executive Director | Signed report and mentioned in interview regarding privacy and catheter bag policies |
| CNA 2 | Certified Nurse Aide | Named in privacy deficiency related to loud communication and catheter bag visibility |
| DON | Director of Nursing | Interviewed regarding privacy, catheter bag policies, change in condition assessments, and positioning |
| Dietary Aide 4 | Observed with improper glove use during food serving | |
| Dietary Aide 11 | Observed with improper glove use and handling of plastic wrap | |
| Dietary Shift Supervisor 7 | Interviewed regarding food storage and cleanliness | |
| CNA 9 | Interviewed regarding food labeling and expiration | |
| RN 10 | Registered Nurse | Interviewed regarding expired food in refrigerator |
| CNA 12 | Interviewed regarding resident positioning devices |
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Aug 20, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440347.
Findings
No deficiencies related to the allegations in Complaint IN00440347 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00440347 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 76
Medicare Census: 5
Medicaid Census: 53
Other Payor Census: 18
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Jun 19, 2024
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaints IN00433861 and IN00435622, as well as the investigation of Residential Complaint IN00433851.
Findings
No deficiencies related to the allegations in complaints IN00433861 and IN00435622 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigated complaints.
Complaint Details
Complaint IN00433861 and Complaint IN00435622 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type: 74
Total Capacity: 74
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 20
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Apr 30, 2024
Visit Reason
This visit was conducted to investigate Nursing Home Complaints IN00432943 and IN00433596, as well as Residential Complaint IN00432599.
Findings
No deficiencies related to the allegations in complaints IN00432943 and IN00433596 were cited. The facility was found to be in compliance with relevant federal and state regulations regarding the investigated complaints.
Complaint Details
Complaint IN00432943 and Complaint IN00433596 were investigated with no deficiencies cited related to the allegations. The investigation of Residential Complaint IN00432599 was included but no findings are detailed.
Report Facts
Census SNF/NF beds: 75
Total census: 75
Medicare census: 3
Medicaid census: 53
Other payor census: 19
Inspection Report
Re-Inspection
Census: 71
Capacity: 133
Deficiencies: 0
Mar 15, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 01/29/2024.
Findings
At this PSR survey, Ascension Living Sacred Heart Village was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 133
Census: 71
Inspection Report
Re-Inspection
Census: 70
Capacity: 70
Deficiencies: 0
Feb 9, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2024-01-08.
Findings
Ascension Living Sacred Heart Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 54
Census Payor Type - Other: 14
Inspection Report
Life Safety
Census: 69
Capacity: 133
Deficiencies: 5
Jan 29, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had multiple deficiencies related to life safety code including failure to protect hazardous storage areas, therapy areas open to corridors, propped open corridor doors, and lack of signage in the oxygen transfilling room.
Severity Breakdown
SS=E: 3
SS=C: 1
SS=D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Emergency preparedness policies lacked documentation for protecting residents from extreme temperatures. | SS=C |
| Storage room E-19 with combustible materials over 50 square feet was not protected as a hazardous area due to a corridor door not being self-closing or automatic closing. | SS=E |
| One of three rehabilitation patient treatment areas was open to the corridor, not meeting separation requirements. | SS=E |
| Nurse Manager office corridor door was propped open, lacking means to keep the door closed and resist smoke passage. | SS=D |
| Liquid oxygen storage/transfer room lacked signage indicating that oxygen transfilling was occurring and smoking was prohibited. | SS=E |
Report Facts
Certified beds: 133
Census: 69
Residents potentially affected: 30
Residents potentially affected: 3
Residents potentially affected: 2
Residents potentially affected: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Ward | HFA Executive Director | Signed report and involved in exit conference |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions | |
| Administrator | Participated in exit conference and review of findings |
Inspection Report
Recertification
Census: 99
Deficiencies: 7
Jan 8, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Residential Complaint IN00424204.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident privacy, failure to investigate an attempted self-harm incident, failure to follow physician orders for cervical spine fracture management, failure to ensure fall precaution interventions, failure to label and date tube feeding formula, failure to follow respiratory care orders and safe handling of respiratory equipment, and failure to remove expired insulin and monitor medication refrigerator temperatures.
Complaint Details
Complaint IN00424204 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 6
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure privacy was maintained for 2 of 24 residents reviewed (Resident 24 and Resident 32). | SS=D |
| Failure to ensure the investigation of attempted self-harm for 1 of 3 residents reviewed (Resident 4). | SS=D |
| Failure to ensure MD orders were followed for cervical spine fracture management in 1 of 24 residents reviewed (Resident 181). | SS=D |
| Failure to ensure fall precaution interventions were made available to direct care staff members for 1 of 2 residents reviewed (Resident 15). | SS=D |
| Failure to ensure tube feeding formula was labeled and dated for 1 of 1 resident reviewed (Resident 71). | SS=D |
| Failure to ensure physician orders were followed and safe handling of respiratory equipment was completed for 4 of 24 residents reviewed (Resident 9, Resident 24, Resident 36, and Resident 68). | SS=E |
| Failure to ensure insulin in a medication cart was removed when expired for 1 of 29 residents and a medication refrigerator temperature was monitored for 1 of 2 medication rooms reviewed (Resident 16). | SS=D |
Report Facts
Census: 99
SNF/NF beds: 71
Residential beds: 28
Medicare residents: 1
Medicaid residents: 80
Other payor residents: 18
Insulin pen expiration date: Dec 1, 2023
Medication refrigerator temperature log entries: 2
Oxygen tubing change dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Beck | RN, DON | Director of Nursing, involved in interviews and plan of correction |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding Resident 181's C-collar use |
| RN 3 | Registered Nurse | Observed medication cart with expired insulin and temperature log review |
| QMA 2 | Qualified Medicine Aide | Interviewed regarding catheter bag privacy and oxygen tubing |
| QMA 4 | Qualified Medication Aide | Interviewed regarding Resident 15 fall incident |
| LPN 5 | Licensed Practical Nurse | Observed oxygen tubing placement on Resident 9 |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Nov 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420653.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00420653 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 14
Inspection Report
Follow-Up
Census: 75
Capacity: 133
Deficiencies: 0
Oct 2, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Complaint Investigation Number IN00415890 to verify correction of previously identified deficiencies.
Findings
At this PSR survey, Ascension Living Sacred Heart Village was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and applicable state and federal regulations.
Complaint Details
Complaint IN00415890 was corrected as of the survey date.
Report Facts
Facility capacity: 133
Census: 75
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Aug 29, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415624.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00415624 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 79
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 22
Inspection Report
Complaint Investigation
Census: 81
Capacity: 133
Deficiencies: 1
Aug 28, 2023
Visit Reason
An investigation of Complaint Number IN00416046 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a). The survey was complaint-related to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Findings
The facility failed to ensure electrical equipment was in safe operation due to standing water and rust around electrical panels and switches in the basement, creating an increased risk of electrical shock to staff. Maintenance actions were initiated to address the water leakage and ongoing monitoring was planned.
Complaint Details
Complaint Number IN00416046 was substantiated with a federal/state deficiency cited at K911 related to electrical safety hazards in the basement.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Electrical equipment was not in safe operation due to standing water and rust around 4 of 4 electrical panels and switches in the basement. | SS=E |
Report Facts
Facility capacity: 133
Census: 81
Deficiency count: 1
Repair timeframe: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Chaisson | Executive Director | Named in relation to exit conference and plan of correction |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Jul 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00412450.
Findings
No deficiencies related to the allegations in Complaint IN00412450 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00412450 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 78
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 58
Census Payor Type - Other: 17
Inspection Report
Re-Inspection
Census: 71
Capacity: 133
Deficiencies: 0
Mar 20, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/09/23 was performed to verify compliance with prior deficiencies.
Findings
At this PSR survey, Ascension Living Sacred Heart Village was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and applicable state and national fire safety codes.
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 9, 2023
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on January 9, 2023.
Findings
Ascension Living Sacred Heart Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 71
Capacity: 133
Deficiencies: 4
Jan 19, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification (LSC) and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, several Life Safety Code deficiencies were identified including failure to provide disconnect switches for cooktops, failure to maintain ceiling construction affecting sprinkler operation, unprotected penetrations in smoke barrier walls, and smoke barrier doors needing repair.
Severity Breakdown
SS=E: 3
SS=C: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 2 cooktops had a locked or restricted switch to deactivate the cooktop when not under staff supervision. | SS=E |
| Failed to maintain ceiling construction in 1 of 2 carports, which could delay sprinkler activation. | SS=C |
| Failed to ensure penetrations through 1 of 4 smoke barrier walls were protected to maintain smoke resistance. | SS=E |
| Failed to ensure 1 of 4 smoke barrier doors were routinely inspected and repaired. | SS=E |
Report Facts
Certified beds: 133
Census: 71
Residents potentially affected: 40
Residents potentially affected: 35
Residents potentially affected: 30
Residents potentially affected: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Deffenbaugh | Administrator | Named during exit conference and signature on report |
| Maintenance Director | Interviewed and involved in observations related to deficiencies |
Inspection Report
Annual Inspection
Census: 19
Capacity: 93
Deficiencies: 2
Jan 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00395563 and a State Residential Licensure Survey.
Findings
The complaint was unsubstantiated due to lack of evidence with no deficiencies related to the allegations cited. Deficiencies were found related to failure to promptly report signs of urinary tract infection for one resident, and failure to ensure safe medication storage for another resident.
Complaint Details
Complaint IN00395563 was investigated and found unsubstantiated due to lack of evidence. No deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure signs of a urinary tract infection were promptly reported to a physician or designee for 1 of 1 resident reviewed (Resident 68). | SS=D |
| Facility failed to ensure safe medication storage for 1 of 1 resident reviewed (Resident 11). | SS=D |
Report Facts
Survey dates: 5
Census Bed Type - SNF/NF: 74
Census Bed Type - Residential: 19
Total Capacity: 93
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 79
Census Payor Type - Private: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Deffenbaugh | Executive Director | Signed the report as Laboratory Director's or Provider/Supplier Representative |
| RN 2 | Registered Nurse | Interviewed regarding medication self-administration and safe storage |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding catheter care and reporting urine irregularities |
| CNA 6 | Certified Nursing Assistant | Observed catheter care and reported urine irregularities |
| DON | Director of Nursing | Interviewed regarding medication storage and corrective actions |
| NP | Nurse Practitioner | Gave order to start antibiotic therapy for Resident 68 |
Inspection Report
Re-Inspection
Census: 78
Deficiencies: 0
Nov 1, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00387787 and IN00387890 completed on August 23, 2022.
Findings
Both complaints IN00387787 and IN00387890 were found to be corrected. The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR.
Complaint Details
This visit was a Post Survey Revisit to the Investigation of Complaints IN00387787 and IN00387890. Both complaints were corrected.
Report Facts
Census: 78
Census Bed Type - SNF/NF: 71
Census Bed Type - SNF: 7
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 50
Census Payor Type - Other: 21
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 2
Aug 22, 2022
Visit Reason
This visit was conducted for the investigation of two substantiated complaints (IN00387787 and IN00387890) related to allegations of abuse at the facility.
Findings
The facility failed to prevent abuse and failed to implement adequate policies and procedures to prevent abuse for one resident (Resident B) on the secured memory care unit. The investigation found that a CNA pushed the resident against a wall causing agitation and distress. The CNA was terminated following the investigation. The facility had prior unsubstantiated allegations against the same CNA. The facility has implemented corrective actions including re-education of staff and ongoing monitoring.
Complaint Details
Complaints IN00387787 and IN00387890 were substantiated. The allegations involved abuse by CNA 2 against Resident B. The facility's investigation and the Indiana Department of Health investigation found CNA 2 pushed the resident against a wall. CNA 2 was terminated. Previous allegations against CNA 2 were unsubstantiated. Multiple staff interviews indicated CNA 2 had an abrasive tone and was firm with residents but was not previously identified as abusive.
Severity Breakdown
SS=G: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to prevent abuse for 1 of 4 residents reviewed (Resident B) involving physical abuse by a staff member. | SS=G |
| Facility failed to develop and implement policies and procedures to prevent abuse, neglect, and exploitation for 1 of 4 residents reviewed (Resident B). | SS=D |
Report Facts
Census: 76
Total Capacity: 76
Medicare Census: 3
Medicaid Census: 60
Other Payor Census: 13
Survey Dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nurse Assistant | Named in abuse finding for pushing Resident B against a wall; terminated following investigation |
| LPN 7 | Licensed Practical Nurse | Witnessed and intervened during abuse incident involving CNA 2 and Resident B |
| Administrator | Interviewed regarding abuse incident and facility actions | |
| Director of Nursing | DON | Interviewed regarding abuse incident and facility actions |
| Assistant Director of Nursing | ADON | Interviewed regarding abuse incident and facility actions |
| Psychiatric Nurse Practitioner | Psych NP | Assessed Resident B following abuse allegations |
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