Inspection Reports for
Cornerstone at the Ranch
103 West Martial Ave, Lafayette, LA, 70506
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Inspection Report — Jul 30, 2025
Routine CMS
Date: Jul 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication management, assessments, care planning, pressure ulcer care, medication storage, garbage disposal, and quality assurance activities at the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to update residents' advanced directives accurately, failure to review gradual dose reduction forms for psychotropic medications, inaccurate Minimum Data Set assessments, incomplete care plans and failure to follow physician orders, inadequate pressure ulcer care resulting in actual harm, improper storage of expired medications, improper disposal of garbage, and ineffective monitoring of Quality Assurance and Performance Improvement (QAPI) projects.
Deficiencies (8)
Failed to ensure each resident's clinical record accurately reflected their advanced directives, specifically Resident #74's DNR status was not updated in the facility's Care Profile Report.
Failed to ensure gradual dose reduction forms for psychotropic medications were reviewed by the physician for Residents #11 and #46.
Failed to ensure the Minimum Data Set (MDS) assessment accurately reflected Resident #76's status, incorrectly coding discharge status.
Failed to ensure residents' care plans and physician orders were followed for 5 residents, including failure to document edema severity, monitor fluid intake, apply ordered arm swath and sling, complete vital signs every shift, and update care plans for code status and hospice admission.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #44, resulting in actual harm due to failure to conduct weekly body audits, report new skin findings, and administer standing wound care orders.
Failed to discard expired medications found in two medication rooms, including Sodium Chloride Tablets, Acetaminophen suppositories, Bisacodyl suppositories, Ferrous Sulfate Elixir, and Vitamin D-3.
Failed to properly dispose of garbage and refuse in the dietary garbage disposal area, with used gloves and trash observed outside the dumpster and the dumpster left open.
Failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program by inadequately monitoring open QA projects related to gradual dose reductions, weekly body audits, and expired medications.
Report Facts
Residents reviewed for advanced directive: 1
Residents reviewed for unnecessary medications: 6
Residents with GDR forms not reviewed: 2
Residents sampled for care plan compliance: 46
Residents with care plan deficiencies: 5
Stage II pressure ulcer size: 1
Stage II pressure ulcer size: 0.5
Expired medications found: 6
Open QA projects monitored: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2DON | Director of Nursing | Confirmed deficiencies related to advanced directives, care plans, vital signs, wound care, and QAPI monitoring |
| S1ADM | Administrator | Interviewed regarding GDR review and garbage disposal area |
| S3ADON | Assistant Director of Nursing | Confirmed expired medications in medication rooms |
| S6LPN | Licensed Practical Nurse | Identified red area on Resident #44 and admitted failure to notify treatment nurse |
| S11LPN | Licensed Practical Nurse | Discovered Stage II pressure ulcer on Resident #44 and conducted assessment |
| S14RN | Registered Nurse | Confirmed physician orders for swath and sling for Resident #12 |
| S2DON | Director of Nursing | Confirmed multiple deficiencies and lack of monitoring |
Inspection Report — Jun 16, 2025
Complaint Investigation CMS
Date: Jun 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation triggered by observations of unsanitary conditions in the kitchen, including rodent droppings and improper food storage, as well as a routine/renewal visit and follow-up on previous violations.
Complaint Details
The complaint visit conducted on 2025-06-12 revealed a critical violation due to presence of rodents in the establishment and non-critical violations including unclean non-food contact surfaces and repeat floor cleanliness issues. The Assistant Administrator signed the notice.
Findings
The facility failed to maintain sanitary conditions in the kitchen, including unclean flooring, presence of rodent droppings, opened and unlabeled food items in the refrigerator for resident supplements, a thick layer of debris on the deep fryer, and an unsecured electrical outlet in the kitchen. These deficiencies had the potential to affect the 79 residents.
Deficiencies (5)
Flooring was not clean
Rodent droppings found in kitchen storage area
Opened and unlabeled food items in refrigerator designated for resident supplements
Thick layer of debris and food residue on the deep fryer
Electrical outlet not sealed and secured properly into the wall in the kitchen
Report Facts
Residents affected: 79
Date of routine/renewal visit: Jun 5, 2025
Date of complaint visit: Jun 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2DM | Dietary Manager | Named in relation to food storage and kitchen sanitation findings |
| S1AssistAdmin | Assistant Administrator | Signed notice of violations and confirmed electrical outlet deficiency |
| S3KS | Kitchen Staff | Observed sweeping floor after rodent droppings were found |
Inspection Report — Nov 6, 2024
Complaint Investigation CMS
Date: Nov 6, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's physician of a significant change in condition and failure to maintain accurate medical records.
Complaint Details
The complaint investigation found that the facility did not notify the physician or nurse practitioner of Resident #3's diarrhea episodes despite documentation and staff awareness. The facility also failed to maintain accurate bowel and bladder charting documentation.
Findings
The facility failed to notify the physician of Resident #3's episodes of diarrhea and failed to maintain accurate bowel charting documentation. Documentation errors were confirmed by multiple staff and administrators, with minimal harm or potential for actual harm to a few residents.
Deficiencies (2)
Failure to notify a resident's physician of significant change in condition related to episodes of diarrhea.
Failure to maintain accurate bowel charting documentation, including incorrect use of size and consistency codes.
Report Facts
Residents affected: 3
Frequency of resident care: 18
Frequency of resident care: 19
Documentation entries: 10
Documentation entries: 6
Documentation entries: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3NP | Nurse Practitioner | Stated he had not been notified of Resident #3's diarrhea episodes |
| S1LPN | Licensed Practical Nurse | Cared for Resident #3 and did not notify physician of diarrhea |
| S2CNA | Certified Nursing Assistant | Reported Resident #3's diarrhea episodes to nurse twice |
| S4CRN | Corporate Registered Nurse / Director of Nursing | Confirmed lack of physician notification despite documentation |
| S5ADON | Assistant Director of Nursing | Confirmed inaccurate bowel charting documentation |
| S6ADM | Administrator | Confirmed documentation by CNAs was not done correctly |
Inspection Report — Sep 24, 2024
Complaint Investigation CMS
Date: Sep 24, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding inaccurate documentation of edema and mood/behavior assessments for sampled residents.
Complaint Details
The complaint investigation found that Resident #2's mood and behavior documentation was inaccurate, with observed behaviors not reflected in the records. Resident #3's edema was documented inconsistently, with nursing assessments not matching medication administration records despite orders to monitor edema daily.
Findings
The facility failed to maintain accurate medical records for two residents by not properly documenting edema assessments and mood/behavior observations as required by physician orders and professional standards.
Deficiencies (2)
Failure to maintain accurate assessment and documentation of edema and mood/behaviors for Resident #2.
Failure to maintain accurate assessment and documentation of edema for Resident #3.
Report Facts
Residents sampled: 3
Residents affected: 2
Dates edema documented as present: 6
Dates edema documented as absent: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN (Licensed Practical Nurse) | Documented inaccurate mood/behavior and edema assessments for Resident #2 and Resident #3; interviewed confirming documentation discrepancies | |
| S2DON (Director of Nursing) | Interviewed and confirmed that monitoring of edema on MAR and daily nursing assessments should match and had not |
Inspection Report — Aug 27, 2024
Routine CMS
Date: Aug 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, staffing, wound care, and infection prevention at Cornerstone at the Ranch nursing home.
Findings
The facility was found deficient in maintaining a clean and homelike environment, ensuring timely response to resident call lights, demonstrating nursing staff competencies in wound care and documentation, and implementing proper infection prevention practices during wound care.
Deficiencies (4)
Failed to maintain a clean, comfortable, and homelike environment by not ensuring walls were clean in resident rooms.
Failed to have sufficient nursing staff with appropriate competencies and skills to promptly respond to a resident's call for assistance.
Failed to ensure nursing staff demonstrated competencies necessary to provide care safely, including weekly skin assessments, accurate wound staging, updating clinical records, obtaining physician orders, and notifying physician or NP of deteriorating wounds.
Failed to provide a safe and sanitary environment by not removing contaminated gloves and performing hand hygiene during wound care.
Report Facts
Residents sampled: 5
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5LPN | Licensed Practical Nurse | Observed delayed response to Resident #R1's call light and described call light response protocol |
| S2DONIP | Director of Nursing/Infection Preventionist | Interviewed regarding call light response protocol, wound care assessments, and infection prevention practices |
| S3TN | Treatment Nurse | Responsible for wound care and skin assessments; observed failing to perform proper hand hygiene and delayed wound care notifications |
| S4HSKSUP | Housekeeping Supervisor | Acknowledged responsibility for cleaning walls in resident rooms |
| S6NP | Nurse Practitioner | Notified of Resident #3's deteriorated wound on 08/27/2024 |
Inspection Report — Jul 10, 2024
Routine CMS
Date: Jul 10, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility standards, including resident care, safety, and regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, cleanliness of wheelchairs, incomplete care plans, inadequate respiratory care, pain management issues, staffing shortages, expired medications, food preference accommodations, medical record documentation, call system functionality, hospice care coordination, and environmental safety.
Deficiencies (14)
Failed to ensure a resident's dignity by failing to provide a covering for a urinary catheter bag for 1 resident (#70).
Failed to ensure cleanliness of wheelchairs for 2 residents (#30 and #35).
Failed to complete a baseline care plan that addressed pain for 1 resident (#178).
Failed to develop and implement a comprehensive person-centered plan of care for 5 residents (#38, #50, #58, #62, #70).
Failed to provide safe and appropriate respiratory care for 2 residents (#36 and #66), including unlabeled oxygen tubing and lack of physician order for oxygen.
Failed to provide safe, appropriate pain management for 1 resident (#178) who complained of pain and did not receive medication.
Failed to provide enough nursing staff to meet resident needs and respond to call lights timely for 2 residents (#58 and #61).
Failed to ensure nursing staff administered ordered PRN medications for itching for 1 resident (#36).
Failed to ensure expired medications were not stored in medication room A.
Failed to honor and accommodate food preferences for 1 resident (#15).
Failed to maintain complete medical records for 1 resident (#43), including lack of documentation of signs, symptoms, and ongoing assessments.
Failed to ensure working call systems in bathrooms and bathing areas for 3 residents (#5, #31, #66).
Failed to provide a safe, sanitary, and comfortable environment by not repairing an exterior window for 1 resident (#66).
Failed to ensure timely hospice care plan updates and availability for 1 resident (#52).
Report Facts
Residents sampled: 41
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 5
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1DON | Director of Nursing | Confirmed dignity deficiency for Resident #70 and lack of physician order for oxygen for Resident #66 |
| S14CNA | Certified Nursing Assistant | Confirmed wheelchair cleanliness issues for Residents #30 and #35 |
| S3MDS | Minimum Data Set Coordinator | Confirmed pain not addressed in baseline care plan for Resident #178 and communication not addressed for Resident #50 |
| S15LPN | Licensed Practical Nurse | Observed unclean catheter tubing for Resident #58 and confirmed Resident #70 did not have glucose sensor |
| S13LPN | Licensed Practical Nurse | Confirmed Resident #70 did not have glucose sensor and confirmed expired medications |
| S2MDS | Minimum Data Set Coordinator | Responsible for Resident #70's care plan and confirmed lack of glucose sensor |
| S5LPN | Licensed Practical Nurse | Confirmed no physician order for oxygen for Resident #66 and lack of pain medication for Resident #178 |
| S11ADON | Assistant Director of Nursing | Confirmed no physician order for oxygen for Resident #66 and lack of pain medication for Resident #178 |
| S18ST | Speech Therapist | Confirmed Resident #50 had severe dysarthria and communication needs not addressed |
| S9LPN | Licensed Practical Nurse | Confirmed lack of documentation for Resident #43's leg condition |
| S6CNA | Certified Nursing Assistant | Confirmed Resident #31's call bell was not functioning |
| S12MP | Maintenance Personnel | Confirmed call lights for Residents #5 and #66 were not working |
| S7LPN | Licensed Practical Nurse | Failed to administer PRN medications for Resident #36's itching |
| S17CORP | Regional Corporate Nurse | Confirmed facility staffing issues |
| S4Maintenance | Confirmed call bells were not routinely checked for function or battery status | |
| S10DM | Dietary Manager | Confirmed food preferences for Resident #15 were not honored |
| S1DON | Director of Nursing | Unaware of missing updated hospice care plan for Resident #52 |
| S7AIT | Confirmed exterior window in disrepair for Resident #66 |
Inspection Report — Jul 10, 2024
Routine CMS
Date: Jul 10, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements, focusing on staffing adequacy, medical record maintenance, and the safety and condition of the physical environment.
Findings
The facility was found deficient in providing adequate nursing staff to meet residents' needs, timely response to call lights, maintaining complete medical records for residents, and ensuring a safe, sanitary, and comfortable environment, including repair of an exterior window.
Deficiencies (3)
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift, evidenced by delayed response to call lights for 2 residents.
Failure to maintain complete medical records for one resident, including lack of documentation of signs, symptoms, and ongoing assessments related to antibiotic treatment and condition of the right lower extremity.
Failure to ensure a safe, sanitary, and comfortable environment as evidenced by an exterior window in disrepair with large cracks covered by tape.
Report Facts
Residents investigated for staffing: 8
Total sample residents: 41
Call light response delay: 30
Length of cracks: 3
Pieces of tape: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S15LPN | Licensed Practical Nurse who failed to answer Resident #58's call bell promptly | |
| S16CNA | Certified Nursing Assistant who did not respond to Resident #61's call light despite hearing announcements | |
| S14CNA | Certified Nursing Assistant who was on break and did not inform other CNA, contributing to delayed response | |
| S17CORP | Regional Corporate Nurse who confirmed facility staffing issues | |
| S9LPN | Licensed Practical Nurse who confirmed lack of documentation for Resident #43's condition and treatment | |
| S1DON | Director of Nursing who stated nurses should document signs, symptoms, and ongoing assessments | |
| S7AIT | Staff who confirmed exterior window was in disrepair |
Inspection Report — May 8, 2024
Complaint Investigation CMS
Date: May 8, 2024
Visit Reason
The inspection was conducted due to complaints regarding a resident with dementia (Resident #1) wandering into other residents' rooms and inadequate supervision and care planning related to this behavior.
Complaint Details
The complaint was substantiated based on observations, record review, and interviews indicating Resident #1 wandered into other residents' rooms multiple times, and the facility failed to adequately address or supervise the resident despite reports from Resident #2's daughter and staff.
Findings
The facility failed to revise the comprehensive care plan to address Resident #1's wandering, staff failed to report incidents of wandering into other residents' rooms, and the facility failed to provide adequate supervision after complaints. Interventions such as placing a reminder sign and increasing activities were not included in the care plan, and supervision was not increased despite reports.
Deficiencies (3)
Failure to revise the comprehensive care plan to include interventions addressing Resident #1's continued wandering.
Staff failing to report continued incidents of Resident #1 wandering into other resident rooms.
Failure to provide adequate supervision of Resident #1 after complaints of wandering into other resident rooms.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 DON | Director of Nursing | Conducted in-service training and interviews; acknowledged lack of reporting and inadequate interventions for Resident #1's wandering. |
| S2 LPN | Licensed Practical Nurse | Interviewed regarding Resident #1's wandering behavior and staff responses. |
Inspection Report — Dec 7, 2023
Complaint Investigation CMS
Date: Dec 7, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify residents' representatives of changes in condition, failure to follow grievance policies, failure to provide services according to physician orders, and deficiencies in infection control and influenza vaccination practices.
Complaint Details
The complaint investigation revealed failures in notification to residents' representatives about changes in condition and injuries, failure to initiate grievances, failure to follow physician orders for monitoring, and significant infection control deficiencies during an influenza outbreak.
Findings
The facility failed to notify residents' representatives of changes in condition for 2 of 7 sampled residents, failed to initiate grievances for 2 of 9 sampled residents, failed to monitor temperature after flu vaccination for 1 resident, and failed to maintain an effective infection control program during an influenza outbreak. The facility also delayed ordering and administering influenza vaccines, failed to isolate symptomatic residents promptly, and did not perform proper hand hygiene.
Deficiencies (7)
Failure to immediately inform Resident #6's representative of positive Influenza Type A test and Resident #7's representative of injuries sustained after an incident.
Failure to initiate grievances voiced by residents or their representatives for 2 out of 9 sampled residents.
Failure to monitor Resident #5's temperature for 72 hours after receiving the flu vaccine as ordered.
Failure to administer influenza vaccines timely and failure to maintain an effective infection control program during an influenza outbreak affecting 6 residents and 10 staff.
Failure to report influenza outbreak to public health, failure to annually review infection prevention policies, and failure to perform hand hygiene between contacts with residents.
Failure to ensure Infection Preventionist effectively managed influenza outbreak including timely isolation of symptomatic residents, timely follow-up on influenza tests, and documentation of surveillance and corrective actions.
Failure to obtain influenza vaccines timely and failure to administer vaccines to eligible residents after receipt, resulting in delayed vaccination during an outbreak.
Report Facts
Residents tested positive for influenza: 6
Staff tested positive for influenza: 10
Flu vaccines delivered: 57
Residents sampled: 9
Residents affected by notification failure: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S18LPN | Licensed Practical Nurse | Named in failure to notify resident representatives of injuries sustained by Resident #7 |
| S5AADM | Assistant Administrator | Named in failure to initiate grievances and failure to notify resident representatives |
| S2DON | Director of Nursing | Named in failure to order flu vaccines timely and failure to manage infection control |
| S3ADON | Assistant Director of Nursing | Named in failure to order flu vaccines timely and failure to manage infection control |
| S12LPN | Licensed Practical Nurse | Observed failing to perform hand hygiene between resident contacts |
| S10NP | Nurse Practitioner | Named in failure to notify facility staff about flu vaccine receipt and holding |
| S17Pharmacist | Pharmacist | Named in flu vaccine ordering and delivery |
Inspection Report — Jun 28, 2023
Routine CMS
Date: Jun 28, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements and investigate complaints related to resident care, medication administration, grievance handling, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to evaluate resident competency for self-administering medications, failure to address resident grievances, inconsistent documentation of advance directives, inaccurate resident assessments, incomplete care plans, inadequate assistance with activities of daily living, failure to conduct weekly skin assessments, improper respiratory equipment care, insufficient nursing staff, lack of staff training documentation, and food safety violations.
Deficiencies (16)
Failed to evaluate mental and physical competency for self-administering medications for 1 resident (#84).
Failed to consider and act promptly on resident grievances from 01/18/2023 through 06/13/2023 affecting entire census.
Failed to post survey results and complaint investigations from the last 3 years in a place accessible to residents and public.
Failed to ensure all medical records consistently reflected resident's wishes for advance directives for 1 resident (#6).
Failed to complete accurate Minimum Data Set (MDS) assessments for 2 residents (#7, #76).
Failed to develop and implement comprehensive care plans for 2 residents (#7, #84) including contractures, tube feeding rates, wound care, and medication administration.
Failed to provide necessary assistance with activities of daily living for 1 resident (#64), resulting in soiled clothing and bedding left unattended.
Failed to provide appropriate pressure ulcer care and weekly skin assessments for 1 resident (#84).
Failed to follow policy for labeling and handling of tube feeding for 1 resident (#7).
Failed to ensure respiratory equipment was properly stored and masks/tubing changed per protocol for 1 resident (#19).
Failed to provide sufficient nursing staff to meet resident needs as identified in facility assessment.
Failed to ensure nursing staff had required competencies and training including abuse prevention, dementia care, infection control for 4 agency staff.
Failed to ensure medications were administered timely and not left at resident bedside for 1 resident (#35).
Failed to maintain effective infection prevention program including water system management, infection surveillance criteria, and sanitary storage of wound care ointment.
Failed to ensure kitchen staff wore hair coverings and removed expired food items from dry goods storage.
Failed to ensure Medical Director attended quarterly Quality Assessment and Assurance meetings.
Report Facts
Residents affected: 1
Residents affected: 86
Residents affected: 36
Nurses needed: 3
Nurses scheduled: 2
Expired food items: 8
Quarterly Quality Assessment meetings missing Medical Director: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Licensed Practical Nurse | Confirmed resident #84 self-administered medication without evaluation |
| S9MDS | Minimum Data Set Nurse | Confirmed resident #84 care plan did not address self-administration |
| S3ADON | Assistant Director of Nursing | Confirmed no evaluation for resident #84 self-administration |
| S27SSD | Social Services Director | Responsible for grievance investigations; unaware of resident council complaints |
| S1ADM | Administrator | Acknowledged failure to address resident grievances and incomplete facility assessment |
| S4LPN | Licensed Practical Nurse | Performed wound care with improperly stored ointment for resident #7 |
| S2DON | Director of Nursing/Infection Preventionist | Confirmed weekly skin assessments not performed and improper ointment storage |
| S5LPN | Licensed Practical Nurse | Confirmed inconsistent advance directive documentation for resident #6 |
| S12LPN | Licensed Practical Nurse | Observed resident #84 with swelling and no administration of ordered medication |
| S14DM | Dietary Manager | Confirmed expired food items and lack of hair coverings in kitchen staff |
| S3ADON | Assistant Director of Nursing | Confirmed improper medication administration and ointment storage |
| S22Asst ADM | Assistant Administrator | Confirmed lack of training documentation for agency staff |
Inspection Report — May 31, 2023
Complaint Investigation CMS
Date: May 31, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to implement a comprehensive person-centered care plan for Resident #1, including medication administration, edema monitoring, blood work, and weekly skin audits.
Complaint Details
The investigation was complaint-driven, focusing on Resident #1's care deficiencies including medication administration errors, failure to monitor edema, failure to conduct ordered blood work, and failure to perform weekly skin audits. The complaint was substantiated based on record reviews and staff interviews.
Findings
The facility failed to administer medications as ordered, monitor edema, conduct ordered blood work, and perform weekly skin checks for Resident #1. Staff also failed to transcribe physician orders properly, resulting in missed medication administration and monitoring. Interviews confirmed these failures and lack of appropriate nursing competencies.
Deficiencies (2)
Failed to implement a complete care plan for Resident #1, including medication administration, edema monitoring, blood work, and weekly skin audits.
Failed to have nursing staff with appropriate competencies to provide nursing and related services, including failure to have prescribed medication available and failure to transcribe orders.
Report Facts
Residents affected: 6
Missed doses of Alprazolam: 17
Missed doses of Alprazolam: 12
Prescription tablets: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4LPN | Wound Care Nurse | Interviewed regarding skin audits and weekly skin checks |
| S1DON | Director of Nursing | Interviewed regarding medication administration, order transcription, and care plan compliance |
| S6LPN | Licensed Practical Nurse | Interviewed regarding medication administration failures and order transcription |
| S7NP | Nurse Practitioner | Ordered medications and blood work for Resident #1 |
| S2ADON | Assistant Director of Nursing | Interviewed regarding care plan and order transcription |
| S3ADON | Assistant Director of Nursing | Interviewed regarding care plan and order transcription |
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