Inspection Report
Plan of Correction
Deficiencies: 0
Sep 8, 2025
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2025-07-31 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming measures were put in place to correct deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2025-09-03.
Report Facts
Annual survey date: Jul 31, 2025
Desk review date: Sep 8, 2025
Compliance effective date: Sep 3, 2025
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 8, 2025
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2025-07-31 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation. The State Agency recommended the facility be placed back in compliance effective 2025-09-03.
Inspection Report
Life Safety
Census: 57
Deficiencies: 1
Jul 31, 2025
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code (LSC) and fire alarm system requirements at Dunbar Village Terrace.
Findings
The facility failed to maintain a complete manual fire alarm system as required by NFPA 72 and NFPA 101, evidenced by a trouble signal on the fire alarm panel that could not be reset immediately. The fire alarm was still functional and able to notify emergency forces. A plan of correction was initiated to address the issue.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain a complete manual fire alarm system as directed by NFPA 72 Chapter 10 and NFPA 101 section 9.6, with a trouble signal on the fire alarm panel affecting all smoke compartments and all 57 residents. | SS = D |
Report Facts
Residents affected: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Unable to reset fire alarm panel to normal mode; responsible for testing and corrective actions | |
| Maintenance Technician | Involved in staff inservicing and monitoring the fire alarm annunciator panel | |
| Registered Nurse Supervisor | Participated in monitoring the fire alarm annunciator panel |
Inspection Report
Annual Inspection
Census: 57
Capacity: 60
Deficiencies: 3
Jul 31, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 7/28/25 through 7/31/25 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to medication administration, food safety, and resident record accessibility. Specific issues included failure to assess resident capability for self-administration of medication, improper food storage leading to contamination risk, and nurse practitioner visit notes not being readily accessible to nursing staff.
Severity Breakdown
SS = D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure services were provided in accordance with professional standards during medication administration; resident self-administered nasal sprays without proper assessment. | SS = D |
| Food was not stored in a safe and sanitary manner to prevent contamination and deterioration; moldy fruit and improper storage of cups in food bins observed. | SS = D |
| Clinical records, including nurse practitioner visit notes, were not readily accessible to licensed nursing staff responsible for resident care. | SS = D |
Report Facts
Deficiencies cited: 3
Census: 57
Total licensed capacity: 60
BIMS score: 13
Dates of Plan of Correction completion: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Assessed Resident #11 for medication self-administration and oversaw corrective actions. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Observed administering nasal sprays to Resident #11 and acknowledged lack of assessment for self-administration. |
| Dietary Manager | Dietary Manager | Removed contaminated food items and inserviced dietary staff on food storage procedures. |
| Registered Dietitian | Registered Dietitian | Informed about kitchen findings and confirmed corrective actions. |
| Administrator | Administrator | Acknowledged findings related to food safety and communication issues with nurse practitioner notes. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reported on Resident #5's pain medication changes and lack of nurse practitioner notes in EHR. |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 2
Jul 31, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 7/28/25 to 7/31/25 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance with medical records management and safe food handling procedures. Specifically, nurse practitioner visit notes were not readily accessible to licensed nursing staff, and food items including moldy fruit and improper storage practices were observed in the kitchen.
Severity Breakdown
Level II: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure that all clinical records, including nurse practitioner visit notes, were readily accessible to licensed nursing staff responsible for resident care. | Level II |
| Failed to ensure that food was stored in a safe and sanitary manner to prevent contamination and deterioration. | — |
Report Facts
Residents present: 57
Sampled residents: 15
Moldy fruit observed: 7
Oranges observed: 8
Lemons observed: 2
Plan of correction completion dates: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Assessed Resident #5 and explained NP visit notes accessibility issues |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding Resident #5's pain medication and NP notes |
| Administrator | Administrator | Explained communication processes and EHR system incompatibility |
| Dietary Manager | Dietary Manager | Removed moldy fruit and cups from food storage and inserviced dietary staff |
| Registered Dietitian | Registered Dietitian | Informed of kitchen findings and confirmed corrective actions |
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 29, 2025
Visit Reason
The visit was conducted as the annual survey to assess the facility's compliance with applicable provisions of the 2012 Edition of the Life Safety Code and emergency preparedness requirements.
Findings
The facility was found to be in compliance with the Life Safety Code after a desk review of corrective measures following the annual survey. The emergency preparedness survey revealed no deficiencies.
Report Facts
Survey date: Jul 29, 2025
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
Aug 21, 2024
Visit Reason
The State Agency conducted a complaint investigation related to Dietary Services at the facility on 08/21/2024.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the survey.
Complaint Details
Complaint investigation CI MS #25963 related to Dietary Services; no deficiencies were cited.
Report Facts
Licensed beds: 60
Resident census: 60
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 21, 2024
Visit Reason
The State Agency conducted a complaint investigation related to Dietary Services at the facility.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited.
Complaint Details
Complaint Investigation (CI MS #25963) related to Dietary Services; no deficiencies found.
Inspection Report
Complaint Investigation
Census: 57
Capacity: 60
Deficiencies: 0
Jul 25, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #25387) at the facility on 7/25/24 for nursing services and equipment not maintained.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation (CI MS #25387) was investigated for nursing services and equipment not maintained; no deficiencies were found.
Report Facts
Licensed beds: 60
Census: 57
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 25, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #25387, at the facility on 7/25/24 related to nursing services and equipment not maintained.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited.
Complaint Details
Complaint Investigation MS #25387 was investigated for nursing services and equipment not maintained and was found to be unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 5, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-01-19 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, and the agency recommended the facility be placed back in compliance effective 2024-02-27.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 5, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-01-19 to verify corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility had implemented measures to correct deficient practices and sustain compliance. The State Agency recommended the facility be placed back in compliance effective 2024-02-27.
Report Facts
Survey completion date: Jan 19, 2024
Inspection Report
Annual Inspection
Census: 57
Capacity: 60
Deficiencies: 5
Jan 19, 2024
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigation regarding dietary services and quality of care including food contamination, food cold, residents being left alone in dining room while eating, freezer and refrigerator temperatures, hot box functionality, and disposal to sink issues.
Findings
The complaint investigation resulted in no citations. The annual recertification survey found the facility was not in compliance with Medicare and Medicaid participation requirements and cited deficiencies related to comprehensive care plans, bowel/bladder incontinence and catheter care, tube feeding management, bedrails, and psychotropic medication use.
Complaint Details
Complaint Investigation CI MS #23851 regarding dietary services and quality of care including food contamination, food cold, residents being left alone in dining room while eating, freezer and refrigerator temperatures not kept up to date, hot box not working, and disposal to sink not working properly. No citations were related to the complaint investigation.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to develop comprehensive care plan interventions related to a resident with full length bed rails and a resident with an indwelling catheter. | SS=D |
| Failed to ensure indwelling catheter tubing was stabilized to prevent trauma and failed to provide proper incontinence care for two residents. | SS=D |
| Failed to date and label a tube feeding bag for a resident receiving tube feeding management. | SS=D |
| Failed to inform a resident or resident representative of the risks and benefits of full length bed rails prior to installation. | SS=D |
| Failed to ensure PRN psychotropic medications were discontinued after 14 days or had documented indication for continued use with a designated time frame. | SS=D |
Report Facts
Census: 57
Total Capacity: 60
Deficiencies cited: 5
Tube feeding rate: 70
BIMS score: 14
BIMS score: 14
BIMS score: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Minimum Data Set/Care Plan Nurse | Developed and revised comprehensive care plans for Residents #1 and #52 |
| Assistant Director of Nurses | ADON | Evaluated residents and ensured no negative effects from deficiencies; involved in audits and education |
| Director of Nursing | DON | Evaluated residents, provided education, conducted audits, and oversaw corrective actions |
| Certified Nursing Assistant #4 | CNA | Failed to provide proper incontinence care for Resident #29 |
| Lead Certified Nursing Assistant | Lead CNA | Counseled CNA #4 on proper incontinence care |
| Licensed Practical Nurse #6 | LPN | Confirmed tube feeding bags were not dated or labeled |
| Licensed Practical Nurse #3 | LPN | Confirmed Resident #1 had full length bed rails |
| Maintenance Director | Conducted audits of bed rails and reported findings | |
| Administrator | Confirmed lack of bed rail policy and informed consent; involved in education and audits | |
| Nurse Practitioner | NP | Acknowledged missed stop date on psychotropic medication for Resident #44 |
Inspection Report
Annual Inspection
Deficiencies: 1
Jan 19, 2024
Visit Reason
The State Agency conducted an annual recertification survey and a Complaint Investigation regarding dietary services and quality of care including food contamination, food cold, residents being left alone in the dining room while eating, freezer and refrigerator temperatures not kept up to date, hot box not working, and disposal to sink not working properly.
Findings
No citations were related to the complaint investigation. However, during the annual recertification survey, the facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm and was cited for M635.
Complaint Details
Complaint Investigation CI MS #23851 was conducted regarding dietary services and quality of care issues including food contamination, food cold, residents left alone in dining room while eating, freezer and refrigerator temperatures not kept up to date, hot box not working, and disposal to sink not working properly. No citations were issued related to the complaint.
Deficiencies (1)
| Description |
|---|
| Facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement cited as M635. |
Inspection Report
Annual Inspection
Census: 57
Capacity: 60
Deficiencies: 5
Jan 19, 2024
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation regarding dietary services and quality of care issues including food contamination, food cold, residents being left alone in the dining room while eating, freezer and refrigerator temperatures not being kept up to date, hot box malfunction, and disposal to sink not working properly.
Findings
No citations were related to the complaint investigation. However, during the annual recertification survey, the facility was found not in compliance with Medicare and Medicaid participation requirements and was cited for deficiencies F656, F690, F693, F700, and F758.
Complaint Details
Complaint Investigation CI MS #23851 was conducted regarding dietary services and quality of care issues including food contamination, food cold, residents being left alone in dining room while eating, freezer and refrigerator temperatures not kept up to date, hot box not working, and disposal to sink not working properly. No citations were issued related to the complaint.
Deficiencies (5)
| Description |
|---|
| Deficiency F656 cited |
| Deficiency F690 cited |
| Deficiency F693 cited |
| Deficiency F700 cited |
| Deficiency F758 cited |
Report Facts
Census: 57
Total licensed capacity: 60
Deficiencies cited: 5
Inspection Report
Annual Inspection
Deficiencies: 1
Jan 19, 2024
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation regarding dietary services and quality of care, including food contamination, food cold, residents being left alone in the dining room while eating, freezer and refrigerator temperatures not kept up to date, hot box not working, and disposal to sink not working properly.
Findings
No citations were related to the complaint investigation. However, during the annual recertification survey, the facility was found not in compliance with state licensure requirements due to failure to date and label a tube feeding bag for one resident, resulting in a Level II deficiency.
Complaint Details
Complaint Investigation MS #23851 was related to dietary services and quality of care issues including food contamination, food cold, residents left alone in dining room while eating, freezer and refrigerator temperatures not kept up to date, hot box not working, and disposal to sink not working properly. No citations were issued related to the complaint.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to date and label a tube feeding bag for one resident reviewed for tube feeding management. | Level II |
Report Facts
Tube feeding rate: 70
Deficiency completion date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Failed to date, time, and label the tube feeding bag and water bag; confirmed the bags were not labeled during observation and interview. |
| Assistant Director of Nurses | Assistant Director of Nurses | Evaluated Resident #4 on 1/17/2024 to ensure no distress or negative side effects due to unlabeled tube feeding bag. |
| Director of Nursing | Director of Nursing | Counseled LPN on 1/18/2024; explained expectation for staff to follow labeling procedures; conducted inservice training for nurses beginning 1/30/2024. |
| Registered Nurse | Registered Nurse | Counseled LPN who failed to label tube feeding bag and water bag. |
Inspection Report
Life Safety
Deficiencies: 0
Jan 18, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Jan 18, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 48
Capacity: 60
Deficiencies: 0
Sep 15, 2022
Visit Reason
The State Agency conducted a complaint investigation based on three complaint investigations (CI MS #18674, CI MS #18957, and CI MS #19578) at the facility from 09/14/22 through 09/15/22.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. None of the complaints were substantiated and no deficiencies were cited.
Complaint Details
Complaints related to medications (MS #18674), facility staffing and call lights not answered (MS #19578), and resident grooming, visitation, turning and repositioning residents, and residents dressed improperly (MS #1957) were all not substantiated.
Report Facts
Complaint Investigations: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 14, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 09/14/22 through 09/15/22 related to three complaint numbers: MS #18674, MS #18957, and MS #19578.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. None of the complaints were substantiated and no deficiencies were cited.
Complaint Details
The State Agency did not substantiate MS #18674 related to medications, MS #19578 related to facility staffing and call lights not answered, and MS #1957 related to resident grooming, visitation, turning and repositioning residents, and residents dressed improperly.
Inspection Report
Annual Inspection
Census: 49
Capacity: 70
Deficiencies: 0
May 3, 2021
Visit Reason
The State Agency conducted Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements inspection from 4/28/21 through 5/3/21.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.
Inspection Report
Annual Inspection
Census: 49
Capacity: 70
Deficiencies: 0
May 3, 2021
Visit Reason
The State Agency conducted an annual recertification survey from 4/28/21 to 5/3/21 to determine compliance with Medicare and Medicaid requirements for participation.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid requirements for participation.
Inspection Report
Life Safety
Deficiencies: 0
Apr 27, 2021
Visit Reason
The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Apr 27, 2021
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited.
Inspection Report
Deficiencies: 1
Dec 14, 2020
Visit Reason
The inspection was conducted to review the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 12/07/2020 to 12/13/2020, as required by regulation, which had the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Routine
Census: 51
Capacity: 60
Deficiencies: 0
Nov 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and implementation of CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Routine
Census: 48
Capacity: 70
Deficiencies: 0
May 25, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 48
Total licensed capacity: 70
Inspection Report
Abbreviated Survey
Census: 48
Capacity: 70
Deficiencies: 0
May 25, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 48
Total licensed capacity: 70
Inspection Report
Annual Inspection
Census: 62
Capacity: 70
Deficiencies: 1
Jul 25, 2019
Visit Reason
The State Agency conducted an annual recertification survey along with a complaint survey from 7/23/19 to 7/25/19. The complaint was related to Admission, Transfer, and Discharge Rights, but was not substantiated.
Findings
The facility was found not in substantial compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to failure to complete a comprehensive Significant Change in Status Minimum Data Set (MDS) assessment within 14 days for one resident admitted to hospice services.
Complaint Details
Complaint CI MS #15942 related to Admission, Transfer, and Discharge Rights was investigated and not substantiated; no deficiencies were cited related to the complaint.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete Resident #45's comprehensive Significant Change in Status Minimum Data Set (MDS) assessment within 14 days of determining the resident's status change of admitting to hospice. | SS=D |
Report Facts
Deficiencies cited: 5
Residents reviewed: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | MDS Coordinator | Named in relation to the failure to complete the comprehensive Significant Change in Status MDS assessment. |
| Licensed Practical Nurse #1 | MDS and Care Plan Coordinator | Named in relation to the failure to complete the comprehensive Significant Change in Status MDS assessment. |
| Director of Nurses | DON | Inserviced staff on the Resident Assessment Instrument and responsible for oversight of correction. |
Inspection Report
Annual Inspection
Census: 62
Capacity: 70
Deficiencies: 2
Jul 25, 2019
Visit Reason
The State Agency conducted an annual recertification survey along with a complaint survey from 7/23/19 to 7/25/19. The complaint was related to Admission, Transfer, and Discharge Rights, but was not substantiated.
Findings
The facility was found not in compliance with the Minimum Standards for The Institutions For The Aged And Infirm, citing state statutes M 620 and M 815. Deficiencies included failure to provide proper catheter care to prevent trauma to the bladder for one resident and failure to maintain the kitchen in a manner to prevent cross contamination and food borne illnesses.
Complaint Details
Complaint CI MS #15942 related to Admission, Transfer, and Discharge Rights was investigated and not substantiated; no deficiencies were cited related to the complaint.
Severity Breakdown
Level II: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide proper catheter care to prevent the possibility of trauma to the bladder for one resident (Resident #34). | Level II |
| Failed to maintain the kitchen in a manner to prevent cross contamination and food borne illnesses, including uncleaned hand towels on the tray line, failure to clean thermometer between food temperature checks, and failure to wear proper hair restraints. | — |
Report Facts
Census: 62
Total Capacity: 70
Deficiencies cited: 2
Food temperatures: 187
Food temperatures: 181
Food temperatures: 197
Food temperatures: 190
Food temperatures: 183
Food temperatures: 173
Food temperatures: 194
Chemical strip reading: 200
Freezer temperature: -15
Milk cooler temperature: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant #2 | CNA | Counseled by Director of Nurses for improper catheter care |
| Director of Nurses | DON | Assessed Resident #34 and counseled CNA #2 on catheter care |
| Registered Nurse #2 | RN/Assistant Director of Nurses | Placed catheter securement device on Resident #34 |
| Registered Nurse #1 | RN/Care Plan and Minimum Data Set Coordinator | Confirmed proper catheter tubing securement |
| Dietary Staff #2 | Dietary Staff | Observed wiping thermometer with unclean towel and improper hand hygiene |
| Dietary Staff #1 | Dietary Staff | Counseled on cross contamination and hand washing; prepared replacement gravy |
| Dietary Staff #5 | Dietary Staff | Counseled on proper hair restraint policy |
| Dietary Staff #6 | Dietary Staff | Counseled on proper hair restraint policy |
| Dietary Manager | Dietary Manager | Counseled dietary staff on food safety and hair restraint policies; monitored compliance |
| Certified Nursing Assistant #1 | CNA | Observed entering kitchen without hair net and not washing hands |
Report
File
dunbar_village_terrace_733_Jul.pdf
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