Inspection Reports for Bedrock Hcs at Abbotsford LLC
600 E ELM ST, ABBOTSFORD, WI, 54405
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 10, 2025, identified deficiencies related to inadequate wound and pressure ulcer care, including incomplete assessments and documentation. Earlier inspections showed a pattern of issues involving resident care, particularly wound treatment, care planning, infection control, and supervision during transfers. Complaint investigations documented failures in abuse prevention, staffing sufficiency, elopement supervision, and safe mechanical lift use, with one substantiated immediate jeopardy finding related to a resident fall causing serious injury; enforcement actions were not listed in the available reports. Most complaints were substantiated or had findings of deficiencies, including a resident injury requiring hospital treatment due to unsafe lift practices. The facility’s inspection history shows ongoing challenges with care and safety practices, with no clear improvement trend evident.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
13.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
198% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
48 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 10, 2025
Visit Reason
The inspection was conducted as a standard annual survey of Abbotsford Health Care Center to assess compliance with professional standards of care, including treatment and wound care for residents.
Findings
The facility failed to provide appropriate treatment and care according to orders and professional standards for residents, specifically inadequate skin and surgical wound assessments and incomplete pressure injury evaluations. Deficiencies were noted in care for three residents regarding surgical incision and pressure ulcer assessments and documentation.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, including lack of documented assessments of surgical wounds for residents R2 and R3.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including incomplete pressure injury assessments for resident R4.
Report Facts
Deficiencies cited: 2
Measurement of pressure injury: 1.5
Measurement of pressure injury: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding wound and pressure injury assessments and documentation deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 29, 2025
Visit Reason
The inspection was conducted following a complaint related to a resident (R1) leaving the facility premises without staff authorization, raising concerns about adequate supervision and safety measures to prevent elopement.
Complaint Details
The complaint investigation focused on an incident where resident R1 left the facility without staff authorization on 07/22/25. The guardian had canceled the resident's appointment, and the facility lacked documentation that R1 signed out when leaving. The guardian refused a wander guard. The facility notified Adult Protective Services but did not implement additional safety interventions. Staff education on elopement procedures was incomplete, and no thorough investigation documentation was provided.
Findings
The facility failed to update R1's care plan with new interventions or monitoring to prevent further elopements and did not ensure adequate supervision to prevent accidents, allowing R1 to leave the premises without staff knowledge. The guardian refused a wander guard, and no additional interventions were implemented to prevent recurrence. Staff education on elopement procedures was incomplete, and documentation of resident sign-out and investigation into the incident was lacking.
Deficiencies (2)
Failure to update resident R1's care plan with new interventions and monitoring to prevent elopement.
Failure to ensure adequate supervision and assistance devices to prevent accidents, allowing resident R1 to leave premises without facility knowledge.
Report Facts
Residents affected: 1
Residents reviewed: 3
BIMS score: 7
Date of elopement evaluation: Jul 2, 2025
Date of care plan initiation: Jul 3, 2025
Date of incident: Jul 22, 2025
Date of staff education: Aug 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding interventions and incident investigation of resident elopement |
| LPN C | Licensed Practical Nurse | Nurse on duty during incident and interviewed about resident elopement |
| CNA D | Certified Nursing Assistant | Interviewed about awareness of elopement and staff education |
| CNA E | Certified Nursing Assistant | Interviewed about awareness of elopement and staff education |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 8, 2025
Visit Reason
The inspection was conducted to investigate complaints related to failure to implement policies and procedures to prevent abuse, neglect, and theft, and failure to revise a resident's care plan after removal of side rails.
Complaint Details
The visit was complaint-related, focusing on allegations of failure to implement abuse prevention policies and failure to revise a resident's care plan. The report does not explicitly state substantiation status.
Findings
The facility failed to implement its abuse prevention policy by not obtaining required background checks for one employee before hire. Additionally, the facility failed to revise the care plan for one resident after removal of side rails, despite the resident's care plan indicating their use.
Deficiencies (2)
Failure to implement policy and procedures related to screening employees for prior history of abuse, neglect, exploitation, or misappropriation of resident property for 1 of 8 employees reviewed.
Failure to revise the care plan for 1 of 3 residents reviewed after removal of side rails.
Report Facts
Employees reviewed: 8
Residents reviewed: 3
Resident cognitive score: 15
Care plan last revised: Jun 20, 2025
Bed rail assessment date: Apr 11, 2025
Audit dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Intern D | Employee for whom background checks were not obtained before hire | |
| Nursing Home Administrator A | Nursing Home Administrator | Interviewed regarding lack of background checks for Intern D and policy implementation |
| Director of Nursing B | Director of Nursing | Interviewed regarding removal of side rails and care plan revision for resident R2 |
| Speech-language Pathologist J | Speech-language Pathologist | Completed audits indicating care plan updates |
Inspection Report
Routine
Census: 48
Deficiencies: 4
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to assess the safety, functionality, sanitation, and comfort of the nursing home environment for residents, staff, and the public.
Findings
The facility did not provide a safe, functional, sanitary, and comfortable environment for all 48 residents. Issues included frayed carpet in multiple hallways, numerous spots on carpets throughout the building, stained bathroom flooring, and walls with punctures, black marks, and missing paint.
Deficiencies (4)
Frayed carpet found on three units in the hallways around metal floor circles and seams.
Multiple dark and white spots on carpets throughout all four units, some measuring up to 22 x 44 inches.
Bathroom floor with a brown stain covering the entire floor in one resident room.
Sections of walls with unfinished sheetrock, puncture marks, black marks, missing paint, and hairline cracks in various locations.
Report Facts
Residents affected: 48
Dark spots on carpet: 18
White spots on carpet: 25
White spots on 200 hallway carpet: 15
Puncture marks in wall: 14
Surveyor interview times: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed about carpet spots and wall/flooring issues; unable to find documentation on repairs |
| MD H | Maintenance Director | Interviewed about carpet spots, flooring condition, and wall punctures; described workload and maintenance challenges |
| RN G | Registered Nurse | Interviewed about carpet spots; unable to identify cause |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfers, care planning, wound care, dietary services, infection control, food safety, and facility environment.
Findings
The facility was found deficient in timely notification to the State Long-Term Care Ombudsman for resident transfers, failure to provide written transfer notices and bed hold information, incomplete and unsafe care plans for residents, inadequate wound care and treatment, insufficient dietary management qualifications, unsanitary food handling and storage practices, infection control lapses including improper catheter bag positioning and contaminated dressing procedures, and unsafe, unsanitary environmental conditions including frayed carpets and stained floors.
Deficiencies (8)
Failure to provide timely notification to the State Long-Term Care Ombudsman for resident transfers.
Failure to notify residents or representatives in writing about bed hold policies during hospital transfers.
Failure to develop and implement complete, person-centered care plans addressing all resident needs and preferences.
Failure to provide appropriate wound treatment and care according to orders and recommendations, resulting in delayed or missed treatments.
Dietary Manager not fully qualified and lack of full-time Registered Dietician on staff.
Failure to prepare, store, and distribute food in a sanitary manner, including stacking wet dishes, dirty handwashing sinks, and unlabeled or undated resident food.
Failure to maintain an infection prevention and control program, including catheter bags dragging on the floor and contaminated dressing materials touching the floor.
Failure to maintain a safe, clean, and comfortable environment, including frayed carpets, stained floors, punctured and damaged walls.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 48
Residents affected: 2
Days boot worn: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| J SSD J | Social Services Director | Interviewed about monthly updates to Ombudsman and missing resident transfers |
| B DON B | Director of Nursing | Interviewed about bed hold notices, care plans, wound care, and infection control |
| I RN I | Registered Nurse and Infection Preventionist | Interviewed about catheter bag positioning and care plan processes |
| C DM C | Dietary Manager | Interviewed about qualifications, food safety policies, and kitchen sanitation |
| D DA D | Dietary Aide | Observed and interviewed regarding dishwashing and food handling practices |
| S RN S | Registered Nurse | Observed wound care and interviewed about wound clinic communication |
| T NS T | Nurse Supervisor | Interviewed from wound clinic about wound assessment |
| H MD H | Maintenance Director | Interviewed about facility environmental conditions and carpet/floor maintenance |
| G RN G | Registered Nurse | Interviewed about infection control and environmental conditions |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 30, 2024
Visit Reason
The inspection was conducted following a complaint and incident report regarding unsafe use of mechanical lifts during resident transfers, specifically after an incident on 11/22/24 where a resident was injured due to improper sling size and lift malfunction.
Complaint Details
The visit was complaint-related due to an incident on 11/22/24 where a resident (R1) was injured when a mechanical lift tipped over during transfer, causing a facial bruise and laceration requiring hospital treatment. The complaint investigation found unsafe transfer practices and lack of proper sling sizing and lift maintenance.
Findings
The facility failed to ensure the resident environment was free from accident hazards related to mechanical lifts, including lack of proper sling size verification, inadequate staff training on sling selection, and insufficient maintenance knowledge for lift inspections. An incident resulted in a resident injury requiring hospital treatment. Multiple residents use mechanical lifts and are potentially affected.
Deficiencies (3)
Failure to verify proper sling size or safe functioning of mechanical lifts prior to resident transfers.
Staff unaware of how to determine proper sling size for residents.
Maintenance staff not knowledgeable on lift inspections to ensure safety.
Report Facts
Residents affected: 15
Staff involved in incident: 3
Staff involved in repositioning: 5
Date of incident: Nov 22, 2024
Date of survey completion: Dec 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator A | Nursing Home Administrator | Interviewed regarding sling size determination, lift inspection training, and facility policies |
| Maintenance Director F | Maintenance Director | Responsible for inspecting mechanical lifts but lacked specific training and knowledge on lift safety |
| CNA C | Certified Nursing Assistant | Demonstrated mechanical lift use and provided information on sling size knowledge and lift issues |
| CNA D | Certified Nursing Assistant | Observed transferring resident R2 and unable to identify sling size |
| CNA E | Certified Nursing Assistant | Observed transferring residents R3 and R4 and described sling size determination practices |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 22, 2024
Visit Reason
The inspection was conducted due to complaints and incidents involving resident care, including failure to provide transportation services and failure to ensure safe mechanical lift transfers, as well as concerns about the facility's management and vendor payment status.
Complaint Details
The complaint investigation included review of incidents involving resident R2's delayed transportation back from hospital and resident R1's fall from a Hoyer lift due to inadequate staff assistance. Immediate jeopardy was identified related to the fall incident. The facility took corrective actions and immediate jeopardy was removed.
Findings
The facility failed to provide timely transportation for a resident returning from the hospital, resulting in extended hospital stay. Additionally, the facility failed to ensure adequate supervision during mechanical lift transfers, leading to a resident falling and sustaining serious head injuries. The governing body also failed to maintain current payments to vendors, risking disruption of services.
Deficiencies (3)
Failure to provide needed transportation service for medical necessity resulting in resident remaining at hospital overnight.
Failure to ensure a resident utilizing a Hoyer lift for transfers received adequate supervision and assistance devices, resulting in a fall with serious head injury and immediate jeopardy.
Failure of the governing body to ensure adequate funds were made available to provide for safe and efficient management of the facility, resulting in unpaid vendor invoices and potential disruption of services.
Report Facts
Residents affected: 1
Residents affected: 1
Facility total residents: 51
Balance owed: 2524.65
Balance owed: 5015.63
Balance owed: 26499.64
Balance owed: 54766.03
Balance owed: 4231.66
Balance owed: 18869.38
Balance owed: 160
Balance owed: 484.45
Balance owed: 7758.93
Bed taxes owed: 636403
Civil money penalties owed: 72662
Outstanding balance: 274216.47
Outstanding balance: 17179.5
Outstanding balance: 252.69
Outstanding balance: 21667.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Involved in mechanical lift transfer incident resulting in resident fall |
| NHA A | Nursing Home Administrator | Interviewed regarding transportation issues, vendor payments, and facility management |
| ADON O | Assistant Director of Nursing | Interviewed regarding resident transportation from hospital |
| RN U | Registered Nurse | Interviewed regarding managed care organization transportation responsibilities |
| RN D | Registered Nurse | Responded to resident fall incident and provided care |
| DON B | Director of Nursing | Interviewed regarding mechanical lift transfer policies and corrective actions |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Date: Jun 5, 2024
Visit Reason
The inspection was conducted due to complaints and grievances regarding insufficient nursing staff to meet resident needs, including delayed call light responses and inadequate care.
Complaint Details
The complaint investigation was substantiated by multiple grievances and observations indicating call lights were not answered timely, with some residents waiting 30-90 minutes for assistance. Staff and residents reported feeling rushed and unable to complete care tasks adequately due to staffing shortages.
Findings
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights, residents waiting long periods for assistance, and staff feeling overwhelmed. Multiple residents and staff reported concerns about staffing shortages and the impact on care quality.
Deficiencies (1)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Report Facts
Residents reviewed: 53
Residents affected: 20
Census range: 49
Census range: 57
Nurse to resident ratio: 1
Certified Nursing Assistant coverage: 4
Certified Nursing Assistant coverage: 5
Certified Nursing Assistant coverage: 3
Licensed Staff coverage: 2
Licensed Staff coverage: 3
Licensed Staff coverage: 1
Residents with treatments: 20
Incontinent residents: 31
Residents requiring 2 person assistance: 22
Residents on contact or enhanced barrier precautions: 24
Residents on 30 minute checks: 3
Residents on 1 hour checks: 5
Residents fed by tube: 2
Residents requiring full assistance with meals: 1
Residents requiring supervision and occasional assistance with meals: 3
Falls since May 1: 6
Call light wait times: 45
Call light wait times: 90
Call light wait times: 30
Call light wait times: 60
Open CNA positions: 2
Open nurse positions: 2
Average call ins per week: 2
Inspection Report
Routine
Deficiencies: 3
Date: Feb 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure injury prevention, pain management, and infection control at Abbotsford Health Care Center.
Findings
The facility was found deficient in providing appropriate pressure ulcer care, safe and effective pain management for residents, and maintaining an infection prevention and control program. Specific issues included failure to implement proper repositioning and heel protection for a resident with pressure injuries, inconsistent pain medication administration prior to care, and inadequate hand hygiene and PPE use during care and wound treatment.
Deficiencies (3)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including not applying heel boots, not repositioning as directed, and not following prescribed treatment for resident R2.
Failure to provide safe, appropriate pain management for residents R40 and R258, including inconsistent administration of pain medication prior to care and lack of pain medication orders for a resident with severe pain.
Failure to provide and implement an infection prevention and control program, including inadequate hand hygiene and glove use during care and wound treatment, and failure to use appropriate PPE when entering a resident's room on contact precautions.
Report Facts
Braden Scale Scores: 13
Braden Scale Scores: 14
Weight: 216
Pain Ratings: 7
Pain Medication Administration: 61
Pain Medication Administration: 7
Pain Medication Administration: 72
Pain Medication Administration: 23
Pain Medication Administration: 74
Pain Medication Administration: 36
Pain Ratings: 21
Pain Ratings: 17
Pain Ratings: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN G | Registered Nurse | Named in pressure injury care and treatment observations for resident R2 |
| CNA F | Certified Nursing Assistant | Named in pressure injury care and treatment observations for resident R2 |
| DON B | Director of Nursing | Interviewed regarding pressure injury care, pain management, and infection control policies |
| RN O | Registered Nurse | Named in pain management and infection control observations and interviews |
| CNA D | Certified Nursing Assistant | Named in pain management and infection control observations and interviews |
| RN C | Registered Nurse, Infection Control Preventionist | Interviewed regarding infection control education and PPE use |
| LPN I | Licensed Practical Nurse | Interviewed regarding pain assessment and management for resident R258 |
| RN M | Registered Nurse | Interviewed regarding pain management for resident R258 |
| OT K | Occupational Therapist | Interviewed regarding therapy and pain assessment for resident R258 |
| OTA L | Occupational Therapy Assistant | Interviewed regarding therapy and pain assessment for resident R258 |
Inspection Report
Routine
Census: 55
Deficiencies: 2
Date: Jan 30, 2024
Visit Reason
The inspection was conducted to assess compliance with care plan updates and nurse staffing postings at Abbotsford Health Care Center.
Findings
The facility failed to update a resident's care plan to reflect their hygiene product preference and did not ensure nurse staffing postings included accurate census and staff information for each shift.
Deficiencies (2)
Care plans were not updated with resident's hygiene product preference for 1 of 4 residents reviewed.
The posted nurse staffing information did not include census and correct working staff at the beginning of each shift.
Report Facts
Residents affected: 1
Residents affected: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing B | Director of Nursing | Interviewed regarding care plan update and nurse staffing postings |
| Certified Nursing Assistant C | Certified Nursing Assistant | Interviewed about resident care and hygiene product use |
| Nursing Home Administrator A | Nursing Home Administrator | Interviewed regarding nurse staffing postings |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 19, 2023
Visit Reason
The inspection was conducted due to multiple allegations of abuse involving six residents against a Certified Nursing Assistant (CNA D) at Abbotsford Health Care Center.
Complaint Details
The complaint investigation involved six residents (R2, R6, R7, R8, R9, R10) who alleged various forms of abuse by CNA D, including verbal abuse, physical mistreatment, and refusal of care. The facility did not immediately protect residents or remove the alleged perpetrator until the investigation was completed. The facility also failed to report the allegations to the State Agency in a timely manner and did not conduct a thorough investigation including staff and resident interviews.
Findings
The facility failed to protect residents from physical and verbal abuse by staff, specifically CNA D, in six allegations involving six residents. The facility also failed to timely report the abuse allegations to the State Certification and Survey Agency and did not fully investigate or protect residents during the investigation as required by state law.
Deficiencies (3)
Failed to protect residents from physical and verbal abuse by staff in six allegations involving six residents.
Failed to timely report suspected abuse to the State Certification and Survey Agency as required.
Failed to respond appropriately to all alleged violations by not fully investigating and protecting residents during the investigation.
Report Facts
Residents reviewed for abuse: 15
Residents affected: 6
Date of survey completed: Jul 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in multiple abuse allegations and disciplinary actions |
| DON B | Director of Nursing | Interviewed regarding complaints and disciplinary actions; acknowledged failure to report allegations to State Agency |
| RN L | Registered Nurse | Completed Grievance/Concern Form for incident with R2 |
| CNA K | Certified Nursing Assistant | Completed Grievance/Concern Form for incidents with residents on 06/21/23 |
| NHA A | Nursing Home Administrator | Signed Grievance/Concern Forms |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to submit an accurate and thorough investigation of an incident involving a resident (R2) who fell while smoking outside the facility.
Complaint Details
The complaint investigation involved a fall incident on 02/02/23 where resident R2 fell outside while smoking. The facility's investigation was found inaccurate as it did not reflect the CNA's statement. The fall resulted in a left clavicle fracture confirmed by x-ray. The facility failed to implement fall prevention interventions or smoking cessation measures after the incident.
Findings
The facility failed to conduct an accurate investigation of the fall incident involving R2, did not implement adequate interventions to prevent further falls or address smoking cessation, and did not ensure pharmaceutical services met residents' needs upon admission, including failure to administer medications as ordered and failure to follow medication unavailability policies.
Deficiencies (3)
Facility did not submit an accurate and thorough investigation for 1 of 1 resident involving a fall incident.
Facility did not ensure adequate interventions to prevent continued falls and did not update care plan related to falls and smoking cessation.
Facility failed to provide pharmaceutical services to meet the needs of residents, including failure to administer medications as ordered and failure to follow medication unavailability policy.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 4
Medication administration days missed: 2
Medication administration days missed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Named in fall incident and investigation findings |
| DON B | Director of Nursing | Interviewed regarding fall incident and medication policies |
| NHA A | Nursing Home Administrator | Interviewed regarding resident smoking habits |
| RN C | Registered Nurse | Interviewed regarding medication order and administration process |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 2, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, infection control, care planning, and notification policies during hospital transfers.
Findings
The facility was found deficient in multiple areas including failure to provide written notice of bed-hold policy during hospital transfers for 4 residents, incomplete and unimplemented care plans for 3 residents, improper care and medication administration through a G-tube for 1 resident, failure to prevent significant medication errors for 1 resident, and inadequate infection prevention practices by not offering hand hygiene to 14 residents prior to meals in the Alzheimer Care Unit.
Deficiencies (5)
Failure to provide written notice of the facility bed-hold policy for 4 residents during hospital transfers.
Incomplete and unimplemented care plans for 3 residents, including lack of interventions for fall prevention, contracture management, and assistance with eating.
Failure to check G-tube placement prior to administering medications for 1 resident.
Failure to ensure resident was free from significant medication errors; resident missed doses of anticonvulsant medication leading to seizures and emergency room visit.
Failure to provide and implement an infection prevention and control program by not offering hand hygiene to 14 residents prior to eating in the Alzheimer Care Unit dining room.
Report Facts
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator A | Nursing Home Administrator | Interviewed about bed-hold policy notification failures |
| Director of Nursing B | Director of Nursing | Confirmed bed-hold notification failures, recognized care plan issues, and discussed medication administration expectations |
| Registered Nurse C | Registered Nurse | Observed administering medications via G-tube without checking placement |
| Certified Nursing Assistant M | Certified Nursing Assistant | Interviewed regarding care plan interventions and resident assistance |
| Certified Nursing Assistant L | Certified Nursing Assistant | Interviewed regarding resident assistance with eating and care plan updates |
| Dietician J | Dietician | Interviewed regarding resident diet and care plan updates |
| Social Worker K | Social Worker | Interviewed regarding care conferences and care plan updates |
| Certified Nursing Assistant F | Certified Nursing Assistant | Observed serving residents without offering hand hygiene |
| Certified Nursing Assistant E | Certified Nursing Assistant | Observed serving residents without offering hand hygiene |
| Registered Nurse G | Registered Nurse / Infection Control Preventionist | Interviewed regarding infection control expectations and resident hand hygiene |
| Certified Nursing Assistant D | Certified Nursing Assistant | Interviewed regarding infection control and hand hygiene practices |
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