Inspection Reports for
Highline Post Acute
6060 E ILIFF AVE, DENVER, CO, 80222-5721
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
21 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 11, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding significant medication errors at Highline Post Acute, specifically the failure to ensure residents were free from medication errors.
Complaint Details
The complaint investigation found that Resident #1 did not receive the full prescribed HIV medication regimen from February 2025 until approximately ten months later, resulting in a viral load of 65,900. The medication error was substantiated and created immediate jeopardy to resident health and safety.
Findings
The facility failed to provide Resident #1 with the prescribed HIV medication Biktarvy, instead administering only one component, tenofovir alafenamide, from admission in February 2025 until the medication was discontinued. This error led to immediate jeopardy to resident health, with Resident #1's viral load rising significantly due to lack of proper treatment. The facility implemented a plan of correction including staff education and medication order review to prevent recurrence.
Deficiencies (1)
Failure to administer medications as ordered, specifically the incorrect transcription and administration of HIV medication Biktarvy leading to immediate jeopardy.
Report Facts
Sample residents reviewed: 10
Residents affected: 1
Viral load: 65900
Licensed nurses educated: 43
Licensed nurses total: 57
Licensed nurses not reached for education: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Notified of immediate jeopardy and involved in plan of correction |
| Director of Nursing | DON | Notified of immediate jeopardy, interviewed about medication error, involved in plan of correction |
| Clinical Resource #1 | Notified of immediate jeopardy and involved in plan of correction | |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding Resident #1 medication administration |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding Resident #1 medication administration |
| Medical Director | MD | Interviewed about medication error and facility oversight |
| Facility Pharmacist | Interviewed about medication review process and Resident #1 medication | |
| Assistant Director of Nursing | ADON | Re-educated LPN who transcribed medication order incorrectly and notified Resident #1's family |
| Staff Development Coordinator | SDC | Conducted education for licensed nurses and agency nurses on medication administration policy |
| Hospital Gerontologist | Provided expert opinion on Resident #1's viral load and medication impact |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 2
Date: Jul 14, 2025
Visit Reason
The inspection was conducted due to complaints regarding accident hazards and inadequate supervision in a nursing home, specifically related to two residents who sustained injuries from unsafe practices.
Complaint Details
The complaint investigation found substantiated deficiencies related to accident hazards causing injury to two residents. Resident #1 was burned by overheated food served without temperature checks, and Resident #19 fell out of a wheelchair due to improper seatbelt securing in the facility van.
Findings
The facility failed to ensure a safe environment free from accident hazards, resulting in Resident #1 sustaining a second degree burn from improperly heated food and Resident #19 sustaining a skin tear and abrasions after falling out of a wheelchair in an improperly secured van seatbelt. Corrective actions were partially implemented but not fully effective at the time of survey.
Deficiencies (2)
Failure to ensure staff checked microwaved food for safe temperature prior to serving, resulting in Resident #1 sustaining a second degree burn.
Failure to ensure Resident #19 was properly secured in the facility van, resulting in a fall and skin tear.
Report Facts
Residents reviewed for accident hazards: 9
Residents affected: 2
Burn size: 2
Burn wound measurements: 2
Skin tear size: 4
Skin tear size (alternate measurement): 4
BIMS score Resident #1: 15
BIMS score Resident #19: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in the incident where Resident #1 was served overheated food without temperature check. |
| Assistant Director of Nursing | ADON | Provided education to staff on safe food handling and microwave use after Resident #1's burn incident. |
| Director of Nursing | DON | Interviewed regarding incidents and corrective actions; responsible for audits and staff education. |
| Transportation Driver | Named in the incident where Resident #19 was not properly secured in the van, resulting in a fall. | |
| Regional Director of Plant Operations | Provided training on van safety and conducted safety checks after Resident #19's incident. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 7, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding inadequate supervision and failure to prevent accidents, specifically a fall incident involving Resident #10 on 3/16/25.
Complaint Details
The complaint investigation focused on Resident #10's fall on 3/16/25. The fall was unwitnessed, and the facility failed to document the incident in the risk management system, resulting in no interdisciplinary team meeting to determine the root cause or update the care plan. The Director of Nursing and Regional Clinical Resource were unaware of the fall until the investigation.
Findings
The facility failed to ensure adequate supervision and services to prevent Resident #10's fall and did not identify a root cause for the fall or review the resident's care plan for appropriate fall interventions after the incident. Staff interviews revealed the fall was not documented in the risk management system, and no interdisciplinary team meeting was held to address the fall.
Deficiencies (3)
Failure to ensure adequate supervision and services to prevent Resident #10's fall on 3/16/25.
Failure to identify a root cause for Resident #10's fall.
Failure to review Resident #10's care plan for appropriate fall interventions after the fall.
Report Facts
Residents reviewed for falls: 10
Residents with inadequate supervision: 1
Date of fall: Mar 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding fall incident and facility procedures |
| Regional Clinical Resource | Regional Clinical Resource (RCR) | Interviewed regarding fall incident and facility procedures |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 27, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding the facility's failure to meet residents' activity needs and preferences, and failure to ensure resident safety related to elopement risks.
Complaint Details
The complaint investigation was triggered by concerns about inadequate activities for residents and a serious safety incident involving Resident #1 eloping twice, with the second elopement resulting in an Immediate Jeopardy due to failures in supervision, risk assessment, and response.
Findings
The facility failed to provide adequate activities to meet the socialization and activity needs of residents #6, #4, and #2. Additionally, the facility failed to prevent elopement of Resident #1, who eloped twice, resulting in an Immediate Jeopardy situation due to inadequate supervision, inaccurate risk assessments, and delayed response. The facility also lacked a written hospital transfer agreement and had deficiencies in its quality assurance program.
Deficiencies (4)
Failed to provide activities to meet all residents' needs, specifically for Residents #6, #4, and #2.
Failed to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in Resident #1 eloping twice.
Failed to have a written hospital transfer agreement with one or more hospitals certified by Medicare or Medicaid.
Failed to implement an effective quality assurance program to identify and address facility compliance concerns, including elopement risks.
Report Facts
Residents reviewed for activities: 16
Residents affected by activity deficiency: 3
Exit-seeking behavior days in January 2025: 22
Exit-seeking behavior days in February 2025: 4
Resident #1 BIMS score: 3
Resident #6 BIMS score: 14
Resident #4 BIMS score: 15
Resident #2 BIMS score: 12
Date of survey completion: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Interviewed regarding Resident #1's wandering and cognition decline |
| CNA #2 | Certified Nursing Assistant | Interviewed about Resident #1's behaviors and last seen before elopement |
| LPN #1 | Licensed Practical Nurse | Interviewed about Resident #1's elopement risk and behavior documentation |
| Director of Nursing | Director of Nursing (DON) | Interviewed about Resident #1's elopement, supervision, and facility policies |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed about facility response to elopement and policies |
| Nurse Consultant | Nurse Consultant (NC) | Interviewed about Resident #1's care and facility quality assurance |
| Activities Assistant | Activities Assistant (AA) | Interviewed about activities scheduling and resident reminders |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 3, 2024
Visit Reason
The inspection was conducted following a complaint investigation of physical abuse by a facility employee against a resident on 8/18/2024.
Complaint Details
The complaint investigation was substantiated based on video surveillance and witness testimony. Resident #1 was physically assaulted by a housekeeper (HSK #1) on 8/18/24, causing serious injuries. The facility reported the incident to police and state oversight agencies and took corrective actions.
Findings
The facility failed to protect Resident #1 from physical abuse by a nonclinical employee, resulting in significant bodily injury including brain bleeds and fractures. The abuse was substantiated by video surveillance and witness statements. The facility took immediate corrective actions including suspension and termination of the employee, staff education, and ongoing monitoring.
Deficiencies (1)
Failure to protect Resident #1 from physical abuse by a facility employee resulting in actual harm.
Report Facts
Date of abuse incident: Aug 18, 2024
Date of survey completion: Sep 3, 2024
Resident #1 age: Resident #1 was less than 65 years old
BIMS score: 15
Training completion date: Aug 20, 2024
Monitoring period: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HSK #1 | Housekeeper | Facility employee who physically assaulted Resident #1 |
| LPN #1 | Licensed Practical Nurse | Assessed Resident #1 after abuse incident and reported to DON |
| NHA | Nursing Home Administrator | Interviewed regarding the incident and corrective actions |
| DON | Director of Nursing | Interviewed regarding the incident and corrective actions |
Inspection Report
Routine
Deficiencies: 9
Date: Aug 15, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, medication management, dietary services, and staff training at Highline Post Acute nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide residents reasonable access to communication phones, inadequate assistance with activities of daily living for some residents, improper oxygen therapy administration, lack of annual performance reviews and training for nurse aides, improper medication storage and labeling, failure to provide mechanically altered diets according to orders, failure to accommodate resident food preferences, unsafe food handling and storage practices, and failure to maintain an effective infection prevention and control program.
Deficiencies (9)
Failure to ensure residents had reasonable access to and privacy in their use of communication methods, including lack of operational phones in resident rooms and nurse stations.
Failure to provide timely repositioning, toileting/incontinence care, and proper assistance with meals, snacks, and hydration for residents unable to carry out activities of daily living.
Failure to provide oxygen therapy at the physician-ordered liter flow for residents receiving oxygen.
Failure to complete annual performance reviews and provide regular in-service education for certified nurse aides.
Failure to ensure medications and biologicals were properly labeled with resident names, stored according to route of administration, and stored separately from food in locked compartments.
Failure to provide mechanically altered diets prepared according to prescribed diet textures and failure to accommodate resident food preferences and drink choices.
Failure to handle ready-to-eat foods in a sanitary manner, improper storage of food items in refrigerators and pantry, and failure to maintain safe holding temperatures for food items.
Failure to maintain an infection control program ensuring staff followed proper infection control procedures, including use of enhanced barrier precautions for residents with indwelling devices.
Failure to ensure certified nurse aides received the required 12 hours of annual in-service training for continued competence.
Report Facts
Deficiencies cited: 9
Oxygen liter flow discrepancy: 1
Oxygen liter flow discrepancy: 1
Certified Nurse Aides without annual performance reviews: 5
Certified Nurse Aides without required annual training: 5
Residents observed with pre-poured cranberry juice only: 12
Residents observed with pre-poured cranberry juice only: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Failed to wear gown during feeding tube care for Resident #55 on enhanced barrier precautions |
| CNA #1 | Certified Nurse Aide | Named in failure to provide correct meal items to Resident #63 |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen therapy, medication storage, infection control, and staff training deficiencies |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Provided facility policies and interviewed about staff training and performance reviews |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed about staff training and performance reviews |
| Nutritional Services Director | Nutritional Services Director | Interviewed regarding dietary deficiencies and food handling |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding drink preferences and meal service observations |
| Dietary Aide #2 | Dietary Aide | Observed and interviewed regarding food handling and storage |
| Cook #1 | Cook | Observed and interviewed regarding food preparation and knowledge of mechanically altered diets |
Inspection Report
Routine
Deficiencies: 12
Date: Aug 15, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, infection control, dietary services, and staff training at Highline Post Acute nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had reasonable access to communication devices, timely medication administration, adequate assistance with activities of daily living, implementation of restorative nursing programs, proper oxygen therapy administration, medication storage and labeling, provision of mechanically altered diets according to orders, accommodating resident food preferences, safe food handling and storage, infection control practices for residents on enhanced barrier precautions, and completion of annual nurse aide training and performance reviews.
Deficiencies (12)
Failed to ensure a phone was consistently available and functional for resident use on two units.
Failed to ensure Resident #2's insulin was consistently administered in a timely manner per physician's orders.
Failed to ensure residents unable to carry out activities of daily living received necessary services including timely repositioning, toileting, and meal assistance.
Failed to provide restorative nursing program as recommended for Resident #24 to maintain or improve range of motion.
Failed to provide oxygen therapy in accordance with physician's orders for Residents #19 and #24.
Failed to complete annual performance reviews and provide regular in-service education for five certified nurse aides.
Failed to ensure medications and biologicals were stored and labeled properly, including unlabeled insulin vial, improper medication storage with food, and use of dormitory style refrigerator.
Failed to ensure residents received mechanically altered diets prepared according to prescribed diet orders and IDDSI standards.
Failed to ensure Resident #63 received meal items as ordered and residents in secured unit were offered drink choices at meal time.
Failed to ensure food was prepared, distributed and served under sanitary conditions including improper glove use, unsafe food storage, unlabeled and undated food items, and unsafe food holding temperatures.
Failed to maintain infection control program by not following enhanced barrier precautions for Resident #55 with feeding tube, including failure to wear gown during care.
Failed to ensure five certified nurse aides received required 12 hours of annual in-service training.
Report Facts
Insulin late administration instances: 5
Certified nurse aides without annual performance reviews: 5
Certified nurse aides without required annual training hours: 5
Residents affected by communication phone deficiency: 2
Residents affected by ADL care deficiency: 2
Residents affected by oxygen therapy deficiency: 2
Residents affected by infection control deficiency: 1
Residents affected by dietary/mechanical diet deficiency: 4
Residents affected by food preference deficiency: 1
Residents affected by drink preference deficiency: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding insulin administration and oxygen therapy. |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding oxygen therapy and infection control practices. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding meal tray delivery and resident food preferences. |
| CNA #2 | Certified Nurse Aide | Interviewed regarding resident care and drink preferences. |
| DA #2 | Dietary Aide | Observed and interviewed regarding food handling and meal preparation. |
| NSD | Nutritional Services Director | Interviewed regarding food service deficiencies and food safety. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication, oxygen therapy, infection control, and staff training. |
| RDCS | Regional Director of Clinical Services | Interviewed regarding staff training and performance reviews. |
| IP | Infection Preventionist | Interviewed regarding infection control practices. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jun 6, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining emergency response carts and equipment in safe operating condition.
Findings
The facility failed to ensure that emergency crash carts were regularly checked and properly maintained, including missing backboards, incomplete safety check logs, and absence of essential equipment such as blood pressure cuffs and stethoscopes on some carts.
Deficiencies (4)
Failed to ensure equipment was checked regularly to ensure proper working condition.
Crash carts lacked backboards and were not properly maintained or ready for use.
Crash carts did not contain properly maintained blood pressure cuffs and stethoscopes.
Safety check logs were incomplete or missing for multiple crash carts.
Report Facts
Missing safety checks: 17
Crash carts with missing backboards: 3
Crash carts missing blood pressure cuff and stethoscope: 1
Crash carts inspected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager (UM) | Interviewed regarding crash cart observations and safety check responsibilities. | |
| Director of Nursing (DON) | Interviewed regarding responsibilities for crash cart checks and safety log audits. |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, wound care management, transportation assistance, snack availability, infection control, and environmental safety at Highline Post Acute.
Findings
The facility failed to fully honor resident self-determination regarding shower and oral care preferences for multiple residents, failed to provide appropriate wound care and documentation leading to hospitalization for cellulitis, failed to assist a resident with transportation scheduling, failed to ensure snacks were available on certain units, failed to maintain proper infection control precautions for a resident on isolation, and failed to maintain a safe environment by storing mechanical lifts in hallways blocking handrails.
Deficiencies (6)
Failed to accommodate shower preferences and oral care for residents #1, #4, and #10.
Failed to provide appropriate wound care and documentation for residents #3 and #11, resulting in hospitalization for cellulitis for Resident #11.
Failed to assist Resident #10 with scheduling transportation for a urology follow-up appointment.
Failed to ensure snacks were offered and available on Cherry Creek and Union units.
Failed to maintain infection control precautions for Resident #3; staff did not don appropriate PPE.
Failed to ensure mechanical transfer lifts were not stored in hallways, blocking handrails and impeding resident mobility.
Report Facts
Residents reviewed: 13
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 3
Transfer lifts observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | LPN | Interviewed regarding shower preferences and refusals |
| Certified Nurse Aide #8 | CNA | Interviewed regarding Resident #10's bathing preferences |
| Certified Nurse Aide #6 | CNA | Interviewed regarding Resident #4's bathing preferences and Resident #1's nail care |
| Director of Nursing | DON | Interviewed regarding resident care plans, shower preferences, wound care, transportation, infection control, and environmental safety |
| Nursing Home Administrator | NHA | Interviewed regarding wound care investigation, transportation, and environmental safety |
| Licensed Practical Nurse #1 | LPN | Observed and interviewed regarding wound care and infection control for Resident #3 |
| Certified Nurse Aide #5 | CNA | Observed and interviewed regarding infection control precautions for Resident #3 |
| Licensed Practical Nurse #6 | LPN | Interviewed regarding transportation scheduling for Resident #10 |
| Scheduler | Interviewed regarding transportation arrangements and missed appointments for Resident #10 | |
| Licensed Practical Nurse #3 | LPN | Interviewed regarding snack availability |
| Certified Nurse Aide #1 | CNA | Interviewed regarding snack availability |
| Dietary Manager | DM | Interviewed regarding snack availability and management |
| Director of Therapy Services | DTS | Interviewed regarding wheelchair positioning for Resident #3 |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 9, 2023
Visit Reason
The inspection was conducted to assess compliance with care standards including activities of daily living (ADL) care, skin integrity and incontinence care, and proper disposal of garbage and refuse at the facility.
Findings
The facility was found deficient in providing adequate ADL care for one resident, failing to prevent skin integrity problems due to incomplete cleaning after incontinence for another resident, and improperly disposing of garbage with uncovered dumpsters. Deficiencies were noted with minimal harm potential affecting few to many residents.
Deficiencies (3)
Failed to ensure activities of daily living care was provided to maintain good grooming for Resident #94, including nail care and shaving.
Failed to provide care and treatment to prevent skin integrity problems for Resident #53 by not adequately cleaning after bowel incontinence.
Failed to properly dispose of garbage and refuse; dumpsters were uncovered and one was missing a lid.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Days reviewed: 16
Frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #4 | CNA | Provided care for Resident #94 and observed deficiencies in nail and shaving care |
| Licensed Practical Nurse #5 | LPN | Reported CNAs should provide nail care and shaving two days a week for Resident #94 |
| Director of Nursing | DON | Stated Resident #94 was dependent on staff for nail care and shaving and confirmed deficiencies; also commented on skin care expectations |
| Administrator in Training #1 | AIT | Commented on resident input for personal care and expectations for staff to provide nail care and shaving; also emphasized dumpster lid closure and cleanliness |
| Certified Nursing Assistant #6 | CNA | Provided incontinence care to Resident #53 and initially failed to fully clean feces |
| Licensed Practical Nurse #7 | LPN | Observed incontinence care for Resident #53 and indicated risk of skin breakdown due to incomplete cleaning |
| Maintenance Director | Confirmed dumpsters were uncovered and planned to replace missing lid | |
| Maintenance Aide | Confirmed dumpster lid missing and uncertainty about responsibility for keeping lids closed | |
| Dietary Director | Unaware of missing dumpster lid and planned staff in-service on keeping dumpsters closed | |
| Registered Dietitian | RD | Stated dumpsters should remain closed for sanitation and infection control |
Inspection Report
Annual Inspection
Census: 110
Deficiencies: 7
Date: Nov 21, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, safety, nutrition, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to ensure qualified staff provided colostomy care, inadequate assistance with activities of daily living, unsafe use of non-medical grade power strips for medical equipment, insufficient dietary staffing leading to delayed meal service and resident dissatisfaction, failure to follow menus and provide nutritional needs, and unsanitary kitchen conditions including improper handwashing and dishwashing practices.
Deficiencies (7)
Facility failed to ensure qualified staff provided colostomy care for Resident #78.
Facility failed to ensure cueing and encouragement during meals for residents #27 and #36.
Facility failed to provide a safe environment by allowing medical devices to be plugged into non-medical grade power strips in 18 resident rooms.
Facility failed to employ sufficient dietary support personnel, resulting in prolonged meal wait times and decreased resident satisfaction.
Facility failed to ensure menus were followed and menu items were not omitted without substitutions during meal service.
Facility failed to ensure residents were offered milk as part of the meal service.
Facility failed to maintain a safe, clean, and sanitary kitchen environment including dirty equipment, lack of paper towels, and missing dish machine thermostat.
Report Facts
Residents affected: 37
Residents affected: 3
Residents affected: 18
Residents affected: 79
Census: 110
Meal service delay: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in colostomy care deficiency for Resident #78 |
| DON | Director of Nursing | Interviewed regarding colostomy care and facility policies |
| RN #1 | Registered Nurse | Interviewed regarding colostomy care practices |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding encouragement of resident #27 and #36 during meals |
| MTD | Maintenance Director | Interviewed regarding power strip usage and environmental safety |
| NHA | Nursing Home Administrator | Interviewed regarding power strip corrections and electrical outlet additions |
| DM | Dietary Manager | Interviewed regarding dietary staffing, meal service, and kitchen sanitation |
| FNS #2 | Food and Nutrition Supervisor | Observed and interviewed regarding meal preparation and service |
| CNA #4 | Certified Nurse Assistant | Observed assisting in meal service with improper glove use |
| RD | Registered Dietitian | Interviewed regarding menu compliance and kitchen sanitation |
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