Deficiencies (last 4 years)
Deficiencies (over 4 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
253% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
86% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 5, 2025
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with regulatory requirements, including posting survey results, resident care, wound care, and medication storage.
Findings
The facility was found deficient in multiple areas including failure to post recent survey results in a readily accessible area, failure to ensure follow-up appointments and radiology services for a resident, inadequate wound care for residents with pressure ulcers, and improper labeling and storage of medications on medication carts.
Deficiencies (4)
Failed to post the results of the most recent surveys in a readily accessible area for residents, families, and visitors.
Failed to ensure follow-up appointments and radiology services were obtained for a resident with neurocognitive disorder and shoulder pain.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for residents with wounds.
Failed to store drugs and biologicals in accordance with accepted professional principles; medications were opened and undated on medication carts.
Report Facts
Residents affected: 1
Residents affected: 2
Medication carts observed: 4
Medication carts with deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Central Supply Clerk | Interviewed regarding survey results binder location |
| Staff B | Unit Manager | Interviewed regarding follow-up appointments and orthopedic consults |
| Staff C | Registered Nurse | Observed and interviewed regarding wound care treatment |
| Staff D | Licensed Practical Nurse | Observed and interviewed regarding wound care treatment |
| Staff E | Certified Medication Technician | Observed regarding medication cart storage and labeling |
| Director of Nursing Services | Interviewed regarding survey results accessibility, wound care expectations, and medication storage | |
| Administrator | Interviewed regarding survey results accessibility | |
| Wound Physician | Interviewed regarding wound care expectations |
Inspection Report
Annual Inspection
Census: 132
Capacity: 153
Deficiencies: 6
Date: Sep 5, 2025
Visit Reason
A recertification survey and state licensure survey were conducted at Kent Regency Center from 09/02/2025 through 09/05/2025 to determine compliance with 42 C.F.R. Part 483 for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to failure to post survey results accessibly, quality of care issues including failure to ensure follow-up appointments and treatments, pressure ulcer care deficiencies, improper storage of drugs and biologics, failure to conduct quarterly evaluations of medication technicians, and life safety code violations regarding gas equipment storage.
Deficiencies (6)
Facility failed to post the results of the most recent surveys in a readily accessible area for residents, families, and visitors.
Failure to ensure that a resident received necessary follow-up care and services including radiology services and appointments with Alzheimer's Disease and Memory Disorder Center.
Failure to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice.
Failure to properly label and store drugs and biologics in accordance with accepted professional principles.
Failure to ensure quarterly evaluations of Certified Medication Technicians were conducted, documented, and placed in personnel records.
Failure to maintain oxygen cylinders in accordance with National Fire Protection Association (NFPA) 99, 2012 Edition, including failure to mark full and empty cylinders and improper storage.
Report Facts
Census: 132
Total Capacity: 153
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Medication Technician | Named in deficiency related to failure to conduct quarterly evaluations |
| Staff F | Certified Medication Technician | Named in deficiency related to failure to conduct quarterly evaluations |
Inspection Report
Plan of Correction
Census: 132
Capacity: 153
Deficiencies: 6
Date: Sep 3, 2025
Visit Reason
A comprehensive survey and state licensure survey were conducted at Kent Regency Center from 08/02/2025 through 09/03/2025 to determine compliance with 42 CFR Part 483 and state licensure and emergency preparedness requirements.
Findings
Multiple deficiencies were identified related to emergency preparedness, quality of care, wound care, medication labeling and storage, quarterly evaluations of medication technicians, and life safety code compliance. Plans of correction were provided with specific actions and completion dates.
Deficiencies (6)
The facility failed to make survey results readily available to residents, families, and visitors as required.
Quality of care deficiencies including failure to ensure residents received appropriate treatment and follow-up for orthopedic and neurological conditions.
Failure to ensure proper wound care and prevention of pressure ulcers for affected residents.
Failure to properly label and store drugs and biologicals, including opened and undated medications.
Failure to conduct and document quarterly evaluations for Certified Medication Technicians (CMTs).
Life Safety Code deficiency related to failure to mark and segregate full and empty oxygen cylinders in storage.
Report Facts
Capacity: 153
Census: 132
Deficiencies cited: 5
Completion dates: 2025
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 4, 2024
Visit Reason
An off-site desk audit was conducted on October 4, 2024, to review all previous deficiencies cited on August 21, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 21, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan implementation requirements, specifically focusing on residents with indwelling urinary catheters.
Findings
The facility failed to implement comprehensive person-centered care plans for 4 residents with indwelling urinary catheters, lacking evidence of monitoring urine for sediment, cloudiness, odor, or blood, and failure to monitor signs and symptoms of infection as required.
Deficiencies (1)
Failure to implement comprehensive care plans and monitor urine for sediment, cloudiness, odor, or blood for residents with indwelling urinary catheters.
Report Facts
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing Services | Unable to provide evidence of urine monitoring for Resident ID #2 | |
| Registered Nurse (RN), Staff A | Unable to provide evidence of urine monitoring for Resident ID #3 | |
| Registered Nurse (RN), Staff B | Unable to provide evidence of urine output monitoring for Resident ID #56 and infection monitoring for Resident ID #95 | |
| Director of Nursing Services | Unable to provide evidence that care plans for Residents ID #2, 3, 56, and 95 were implemented |
Inspection Report
Annual Inspection
Census: 2
Capacity: 8
Deficiencies: 4
Date: Aug 21, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, nutrition, staff performance, and food safety at Kent Regency Center.
Findings
The facility was found deficient in implementing comprehensive person-centered care plans for residents with indwelling urinary catheters, maintaining acceptable nutritional status for residents with significant weight loss, completing annual performance reviews for nurse aides, and storing food in accordance with professional food safety standards.
Deficiencies (4)
Failed to implement comprehensive person-centered care plans for residents with indwelling urinary catheters, including monitoring urine for sediment, cloudiness, odor, or blood.
Failed to maintain acceptable nutritional status, including failure to monitor significant weight loss and implement timely interventions for residents.
Failed to complete annual performance reviews for every nurse aide at least once every 12 months.
Failed to store food in accordance with professional standards, including lack of date marking and inadequate covering of food items in the main kitchen refrigerator.
Report Facts
Residents reviewed with indwelling urinary catheters: 4
Residents reviewed for nutritional status: 8
Nurse aides reviewed for annual performance evaluations: 5
Weight loss percentage: 11.5
Weight loss percentage: 7.01
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Unable to provide evidence of urine monitoring for Resident ID #3 |
| Staff B | Registered Nurse (RN) and Unit Manager | Unable to provide evidence of urine monitoring for Residents ID #56 and #95; authored nursing progress note on weight loss |
| Staff C | Registered Dietitian (RD) | Acknowledged failure to obtain re-weigh and implement further interventions for Resident ID #67 |
| Staff D | Registered Nurse Practitioner | Referred weight loss report to RD for Resident ID #67 |
| Director of Nursing Services | Director of Nursing Services | Unable to provide evidence of care plan implementation and annual performance reviews |
| Staff J | Food Safety Manager | Acknowledged failure to cover, label, date, and protect food items in main kitchen refrigerator |
Inspection Report
Annual Inspection
Census: 151
Capacity: 153
Deficiencies: 5
Date: Aug 21, 2024
Visit Reason
A recertification and complaint surveys were conducted from 8/19/2024 through 8/21/2024 to determine compliance with federal regulations for Long Term Care Facilities, including state licensure and emergency preparedness. Additionally, an annual Federal Life Safety Code survey was conducted.
Findings
Deficiencies were identified related to failure to meet professional standards in care plans for residents with indwelling urinary catheters, failure to maintain acceptable nutritional parameters for residents, failure to complete annual performance reviews for nursing aides, and food safety violations including improper food storage and labeling. Life safety code deficiencies were also noted regarding emergency lighting and sprinkler system maintenance.
Deficiencies (5)
Facility failed to provide services meeting professional standards for residents with indwelling urinary catheters, including monitoring urine output and sediment.
Facility failed to maintain acceptable nutritional status parameters for residents, including monitoring significant weight changes.
Facility failed to complete annual performance reviews for nursing aides as required.
Facility failed to store food in accordance with food safety standards, including unlabeled and undated food items.
Facility failed to maintain emergency lighting systems and automatic sprinkler system in compliance with life safety code requirements.
Report Facts
Residents with indwelling urinary catheters not properly monitored: 4
Residents with nutritional deficiencies: 2
Nursing aides missing annual performance reviews: 5
Facility capacity: 153
Facility census: 151
Weight loss percentage: 11.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kellen Moran | Executive Director | Signed plan of correction documents |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 24, 2024
Visit Reason
The inspection was conducted in response to a community complaint reported to the Rhode Island Department of Health on 7/23/2024, alleging that Resident ID #1 was discharged home with another resident's medications.
Complaint Details
The complaint was substantiated as the facility acknowledged that Resident ID #1 was discharged with Resident ID #2's medication. The discharge form was altered without verification, and the Continuity of Care Discharge/Transfer of Patient Form was incomplete.
Findings
The facility failed to reconcile all pre-discharge medications with the resident's post-discharge medications for Resident ID #1, resulting in the resident being discharged with another resident's Levothyroxine medication. The discharge documentation was incomplete, and staff acknowledged the error and failure to verify medication changes.
Deficiencies (1)
Failure to reconcile all pre-discharge medications with the resident's post-discharge medications, resulting in Resident ID #1 being discharged with another resident's medication.
Report Facts
Medication dosage: 88
Medication dosage: 25
Tablets sent home: 15
Date of complaint: Jul 23, 2024
Date of survey: Jul 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Staff A | Licensed Practical Nurse | Acknowledged completing the discharge for Resident ID #1 and altering the medication discharge form without verification |
| Director of Nursing Services | Director of Nursing | Acknowledged the medication error and incomplete discharge documentation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision of a resident while toileting, which resulted in a fall and subsequent intracerebral hemorrhage.
Complaint Details
The complaint investigation was substantiated by findings that Resident ID #1 was left alone in the bathroom for approximately two minutes, resulting in a fall and intracerebral hemorrhage. The Director of Nursing acknowledged the lack of adequate supervision.
Findings
The facility failed to ensure adequate supervision to prevent accidents for Resident ID #1, who was left alone in the bathroom and subsequently found on the floor with a brain bleed diagnosis. Interviews and record reviews confirmed the resident required two-person assistance and was left unattended, leading to the fall.
Deficiencies (1)
Failed to ensure that residents receive adequate supervision to prevent accidents, relative to supervision while toileting for 1 of 4 residents reviewed, Resident ID #1.
Report Facts
Residents reviewed: 4
Residents affected: 1
Incident date: Mar 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nursing Assistant | Assisted resident to toilet and left room to assist other residents |
| Staff B | Nursing Assistant | Assisted resident to toilet, left resident alone to find wheelchair, found resident on floor |
| Director of Nursing Services | Director of Nursing Services | Acknowledged resident was left alone prior to fall and lack of adequate supervision |
| Nurse Practitioner | Nurse Practitioner | Examined resident after fall and recommended hospital transfer |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 29, 2023
Visit Reason
An off-site desk audit was conducted on September 29, 2023, to review all previous deficiencies cited on August 23, 2023.
Findings
Based on an acceptable plan of correction and supporting documentation, the previously cited deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 20, 2023
Visit Reason
The inspection was conducted following a facility-reported incident involving Resident ID #1 who inflicted self-harm with a pocketknife and expressed suicidal ideation. The investigation focused on the facility's failure to provide adequate supervision and communication regarding the resident's mental health status and risks.
Complaint Details
The investigation was triggered by a complaint/incident report regarding Resident ID #1's self-inflicted injuries and suicidal threats. The complaint was substantiated by record review and staff interviews revealing inadequate supervision and communication failures.
Findings
The facility failed to ensure adequate supervision of Resident ID #1, who had self-inflicted cuts and expressed suicidal thoughts. The resident's mental health assessments indicating moderate depression and suicidal ideation were not communicated to the provider timely. Staff intervened after the incident by providing 1:1 supervision and removing harmful items, but the Director of Nursing was unaware of key assessment findings until the survey.
Deficiencies (1)
Failure to ensure that each resident receives adequate supervision based on assessed needs and risks to prevent accidents, specifically related to self-inflicted wounds of Resident ID #1.
Report Facts
MDS Brief Interview for Mental Status score: 10
PHQ-9 depression score: 14
Symptom frequency: 2
Symptom frequency: 6
Date of incident: Sep 16, 2023
Date of care plan: Sep 13, 2023
Date of MDS assessment: Sep 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director of Social Services | Completed MDS Mood section assessment on 9/15/2023 and interviewed resident |
| Staff B | Registered Nurse | Assessed resident on night of incident, removed knife, provided 1:1 supervision |
| Director of Nursing Services | Director of Nursing Services | Unaware of resident's possession of pills and pocketknife and MDS findings until survey |
| Resident's physician | Physician | Expected communication of MDS findings and would have arranged psychiatric services |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 14, 2023
Visit Reason
The inspection was conducted to assess whether the nursing facility services meet professional standards of quality, specifically reviewing a fall incident involving Resident ID #1.
Findings
The facility failed to ensure that staff followed the Falls Management policy when assisting a resident who fell. Staff did not use the required 2+ person assist or a lift to transfer the resident from the floor back to bed, contrary to facility policy.
Deficiencies (1)
Failure to ensure services met professional standards of quality related to fall management and transfer procedures for Resident ID #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Authored progress notes and acknowledged not using 2+ person assist or lift during resident transfer. |
| Staff B | APN | Authored progress note regarding the fall incident. |
| Director of Nursing Services | DNS | Acknowledged facility policy and expectation for staff to use a lift when transferring residents from the floor. |
Inspection Report
Deficiencies: 6
Date: Aug 23, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, infection control, medication administration, staff competencies, and dialysis care at Kent Regency Center.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate pressure ulcer care, inadequate supervision to prevent accidents during meals, failure to provide safe dialysis care, lack of nursing staff competencies, medication errors exceeding 5%, and failure to follow infection prevention protocols during wound care.
Deficiencies (6)
Failure to provide necessary treatment and services to promote wound healing and prevent new pressure ulcers for residents at risk.
Failure to ensure adequate supervision to prevent accidents during meals for a resident with swallowing difficulties.
Failure to provide safe, appropriate dialysis care including assessment of AV fistula as per facility policy.
Failure to ensure nursing staff had appropriate competencies related to CLIA, IV insertion, PPE use, safe resident handling, and AV fistula management.
Medication error rate of 12% observed during medication administration involving insulin and vitamin administration errors.
Failure to follow standard precautions and perform hand hygiene during wound dressing changes.
Report Facts
Medication administration opportunities: 25
Medication errors: 3
Medication error rate: 12
Blood pressure measurements on AV fistula arm: 15
Days without AV fistula assessment: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Acknowledged failure to perform hand hygiene during wound dressing change |
| Staff B | Unit Manager | Interviewed regarding expectation to offload resident's heels |
| Staff C | Nursing Assistant | Revealed resident's offloading boots were not applied |
| Staff D | Registered Nurse | Observed resident's reddened ankle and notified advanced practice nurse |
| Staff E | Advanced Practice Registered Nurse | Expected staff to follow speech therapy recommendations and offload resident's ankle |
| Staff F | Nursing Assistant | Acknowledged failure to provide 1:1 meal supervision |
| Staff G | Registered Nurse | Unaware of resident's AV fistula and took blood pressures on affected arm |
| Staff H | Registered Nurse | Personnel record lacked evidence of competency in CLIA and IV insertion |
| Staff I | Nursing Assistant | Personnel record lacked evidence of competency in Donning/Doffing PPE |
| Staff J | Registered Nurse | Personnel record lacked evidence of competency in Donning/Doffing PPE |
| Staff K | Registered Nurse | Personnel record lacked evidence of competency in safe resident handling |
| Staff L | Registered Nurse | Committed medication administration errors involving insulin and vitamin administration |
| Director of Nursing Services | Director of Nursing | Acknowledged deficiencies and expected staff to follow care plans and competencies |
| Clinical Lead Nurse | Clinical Lead Nurse | Identified lack of AV fistula assessments and initiated physician order |
| Infection Preventionist | Infection Preventionist | Acknowledged blood pressure errors and lack of AV fistula competency |
| Speech Therapist | Speech Therapist | Provided recommendations for safe swallowing and 1:1 supervision |
Inspection Report
Annual Inspection
Capacity: 143
Deficiencies: 7
Date: Aug 23, 2023
Visit Reason
A Recertification Survey was conducted at Kent Regency Center from 08/21/2023 through 08/23/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited in multiple areas including prevention and treatment of pressure ulcers, accident hazards and supervision, dialysis care, nursing staff competencies, medication error rates, infection prevention and control, and life safety code compliance. The facility failed to meet several regulatory requirements as evidenced by observations, record reviews, and staff interviews.
Deficiencies (7)
Failure to provide necessary treatment and services to prevent pressure ulcers for residents at risk.
Failure to ensure residents receive adequate supervision to prevent accidents during meals.
Failure to ensure residents requiring dialysis receive appropriate services consistent with professional standards.
Failure to ensure nursing staff have completed required competencies related to CLIA, IV insertion, PPE, and safe resident handling.
Medication error rate exceeded 5%, with 3 errors resulting in a 12% error rate involving multiple residents.
Failure to establish and maintain an infection prevention and control program to prevent spread of infections.
Failure to maintain minimum 18 inch clearance between sprinkler head deflector and storage of combustible materials as required by Life Safety Code.
Report Facts
Residents reviewed for pressure ulcer prevention: 7
Residents observed during supervision failure: 2
Residents reviewed for dialysis care: 1
Nursing staff reviewed for competencies: 6
Medication administration opportunities observed: 25
Medication errors observed: 3
Facility licensed capacity: 143
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 31, 2023
Visit Reason
The inspection was conducted in response to a community reported complaint submitted to the Rhode Island Department of Health on 2023-07-27 alleging mold on ceiling tiles in the D wing hallway and periodic water leaks.
Complaint Details
The complaint was submitted on 2023-07-27 alleging mold on ceiling tiles in the D wing hallway and periodic water leaks. The complaint was substantiated based on surveyor observations, record reviews, and staff interviews.
Findings
The facility failed to maintain a safe, clean, comfortable, and homelike environment due to mold and black matter on ceiling tiles and air vent covers in multiple units and common areas. Additionally, the facility failed to establish and maintain an effective infection prevention and control program related to Legionella prevention, including inadequate maintenance of HVAC drip pans and lack of evidence of regular preventative maintenance.
Deficiencies (2)
Failed to maintain a safe, clean, comfortable and homelike environment relative to hallway ceiling tiles and registers (air vent covers) with mold and black matter observed in multiple units and common areas.
Failed to establish and maintain an infection prevention and control program related to Legionella prevention, including inadequate maintenance and inspection of HVAC drip pans and condensate pumps.
Report Facts
Date of complaint submission: Jul 27, 2023
Date of surveyor observations and interviews: Jul 31, 2023
Number of units with ceiling tile issues: 3
Number of common areas with ceiling tile issues: 2
Date of last air filter change: Jul 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Acknowledged observations of mold and black matter on ceiling tiles and registers; revealed incomplete HVAC maintenance | |
| Administrator | Unable to provide evidence that the facility maintained a safe, clean, comfortable and homelike environment and that HVAC drip pans received regular preventative maintenance | |
| Maintenance Assistant | Revealed that drip pans in C-unit and D-unit were noted without draining pipes and that not all areas of the facility had been reviewed for concerns |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to assess compliance with facility policies related to resident care, specifically focusing on dietitian notification of significant weight loss for residents.
Findings
The facility failed to follow its policy requiring notification of the dietitian regarding significant weight loss for Resident ID #3, who experienced a 9.5% weight loss over seven days. Interviews with the dietitian and Director of Nurses confirmed no evidence of notification was provided.
Deficiencies (1)
Failed to follow policy related to dietitian notification of significant weight loss for Resident ID #3.
Report Facts
Weight loss percentage: 9.5
Weight loss in pounds: 9.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietitian | Interviewed on 2/23/2023 and unable to provide evidence of notification of weight loss. | |
| Director of Nurses | Interviewed on 2/23/2023 and unable to provide evidence of dietitian notification of weight loss. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 27, 2022
Visit Reason
A Recertification, COVID-19 Vaccination Compliance, and Complaint Survey was conducted at Kent Regency Center from 06/22/2022 through 06/27/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Complaint Details
The survey included a complaint investigation related to COVID-19 infection control practices and food safety. The findings indicated noncompliance with infection control and food safety standards.
Findings
The facility was found not in compliance with food safety requirements related to improper storage and labeling of food items, and infection prevention and control practices including improper use of personal protective equipment (PPE) and failure to disinfect face shields. Corrective actions and education were implemented to address these deficiencies.
Deficiencies (2)
Failed to properly store, distribute, and serve food under sanitary conditions relative to the main kitchen and 2 of 2 unit kitchenettes, including improper thawing and labeling of food items.
Failed to establish and maintain an infection prevention and control program, including improper use of PPE and failure to disinfect face shields when exiting isolation rooms.
Report Facts
Survey dates: 06/22/2022 through 06/27/2022
PPM sanitizer bucket reading: 200
Number of wings observed for PPE compliance: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nursing Assistant | Observed not disinfecting face shield and not wearing gloves while handling resident's meal tray in isolation room |
| Staff B | Nursing Assistant | Observed not disinfecting face shield and not performing hand hygiene when exiting isolation rooms |
| Staff C | Unit Manager | Acknowledged expectations for PPE use and hygiene in isolation rooms |
| Staff D | Licensed Practicable Nurse | Observed not disinfecting face shield when exiting resident rooms and preparing medications |
| Food Service Director | Acknowledged sanitizer bucket reading was not within acceptable range and unable to explain missing thaw dates on health shakes |
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