Deficiencies (last 4 years)
Deficiencies (over 4 years)
15.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
123% worse than New Mexico average
New Mexico average: 7.1 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
117 residents
Based on a October 2024 inspection.
Census over time
Inspection Report
Routine
Deficiencies: 8
Date: May 27, 2025
Visit Reason
The inspection was conducted to evaluate compliance with resident grievance procedures, quality of care including assistance with activities of daily living (ADLs), pain management, physician documentation, staffing adequacy, and dining services.
Findings
The facility failed to adequately investigate and resolve resident grievances, provide timely showers and ADL assistance, manage pain effectively, maintain proper physician documentation, ensure sufficient staffing, and serve meals at posted times. Residents experienced missed showers, inadequate eating assistance, poor grooming, delayed pain medication, and inconsistent physician visits documentation.
Deficiencies (8)
Failure to conduct in-depth investigation and correct grievance allegations for residents.
Failure to provide showers, eating assistance, skin assessments, and grooming care as per physician-approved plan of care for a resident.
Failure to provide activities of daily living assistance including bathing and showering for residents.
Failure to provide quality care for a resident with change in condition in a timely manner.
Failure to effectively manage pain for a resident resulting in long periods of pain without sufficient relief.
Failure to ensure residents had written, signed, and dated physician progress notes after each visit.
Failure to provide enough nursing staff to meet the needs of all residents, resulting in missed showers, inadequate eating assistance, poor grooming, and compromised resident dignity.
Failure to serve meals to residents at posted serving times, disrupting residents' dining experience.
Report Facts
Resident showers completed: 2
Resident showers completed: 5
Resident showers completed: 2
Resident showers completed: 4
Resident showers completed: 3
Resident showers completed: 2
Pain level 5 or greater: 20
Pain level 5 or greater: 4
Residents: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R #13 | Resident who submitted multiple grievances about missing clothes and lack of grievance resolution | |
| Social Services Director | SSD | Interviewed regarding grievance handling and resident concerns |
| Licensed Practical Nurse #10 | LPN | Interviewed about grievance form completion for residents |
| Director of Nursing | DON | Interviewed about grievance process and care expectations |
| Facility Administrator | ADM | Interviewed about grievance process and informal resolution |
| Certified Nurse Aide #1 | CNA | Interviewed about shower assistance and staffing issues |
| Certified Nurse Aide #2 | CNA | Interviewed about shower assistance and staffing issues |
| Certified Nurse Aide #3 | CNA | Interviewed about shower assistance and staffing issues |
| Licensed Practical Nurse #2 | LPN | Interviewed about grooming and showering responsibilities |
| Nurse Practitioner #1 | NP | Interviewed about resident neglect and shower orders |
| Nurse Manager | Interviewed about skin assessments and documentation | |
| Licensed Practical Nurse #1 | LPN | Interviewed about shower log cosigning and concerns |
| Licensed Practical Nurse #3 | LPN | Interviewed about pain management |
| Unit Manager #1 | UM | Interviewed about pain management and grievance |
| Licensed Practical Nurse #4 | LPN | Interviewed about resident pain and behavior |
| Dietary Manager | DM | Interviewed about meal plating and serving times |
| Certified Nursing Assistant #4 | CNA | Interviewed about feeding residents and staffing |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 7
Date: Oct 28, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to notify medical providers of changes in resident condition, failure to provide comprehensive care plans, failure to maintain residents' activities of daily living, failure to provide appropriate treatment and care, failure to follow dietary orders regarding food allergies, failure to serve palatable meals, and failure to maintain sanitary food handling practices.
Complaint Details
The complaint investigation was triggered by allegations of failure to notify medical providers of changes in condition, inadequate care plans, failure to maintain ADLs, improper assessment of chest pain, dietary order violations, poor meal quality, and unsafe food handling. Immediate Jeopardy was identified related to failure to properly assess and notify providers of chest pain in a resident with cardiovascular history.
Findings
The facility failed to notify medical providers of a resident's chest pain, which likely contributed to the resident's death. Care plans lacked comprehensive medical history. Staff failed to assist a resident with toileting needs properly. The facility did not properly assess chest pain complaints, leading to immediate jeopardy. Dietary failures included serving food to a resident with a banana allergy, serving cold and unpalatable meals, and improper food handling practices that could lead to foodborne illness.
Deficiencies (7)
Failed to notify medical provider of resident's intermittent chest pain with history of myocardial infarction.
Failed to ensure care plans included comprehensive medical history information for resident.
Failed to ensure activities of daily living were maintained; resident told to use brief instead of assisted toileting.
Failed to provide quality care by properly assessing resident with chest pain, contributing to resident's death.
Failed to follow dietary orders regarding food allergies for resident with banana allergy.
Failed to serve meals that were attractive, palatable, and at safe temperature for multiple residents.
Failed to serve food under sanitary conditions; improper handling of glasses, bowls, and drinks during meal service.
Report Facts
Resident census: 117
Vital signs: 141
Vital signs: 54
Vital signs: 88
Vital signs: 22
Vital signs: 98.6
Oxygen flow: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Assessed resident with chest pain, did not notify medical provider |
| CNA #2 | Certified Nursing Assistant | Reported resident's chest pain to nurse |
| CNP #1 | Certified Nurse Practitioner | Stated expectation to be notified of chest pain and need for diagnostics |
| LPN #2 | Licensed Practical Nurse | Stated residents with chest pain should be sent to ER and provider notified |
| RN #1 | Registered Nurse | Pronounced resident deceased |
| Director of Nursing | Provided statements on unacceptable practices and education plans | |
| Corporate Supervisor | Stated resident had increased risk for heart attack and care plan deficiencies | |
| Dietary Manager | Stated expectations for food handling and meal service |
Inspection Report
Routine
Deficiencies: 1
Date: Oct 28, 2024
Visit Reason
The inspection was conducted to evaluate the quality and safety of meal service at the facility, focusing on whether food and drink were served palatable, attractive, and at a safe and appetizing temperature.
Findings
The facility failed to ensure meals were served attractive and palatable for 3 of 5 residents reviewed, with issues including cold, late, and unappealing food. Observations and interviews revealed delayed meal service times, poor food presentation, and complaints about taste and temperature.
Deficiencies (1)
Failed to ensure staff served meals that were attractive and palatable for 3 of 5 residents reviewed for meal quality.
Report Facts
Residents reviewed for meal quality: 5
Residents affected: 3
Meal service times: 12.3
Meal service start times: 12.56
Meal service start times: 13.02
Meal service end times: 13.17
Meal service last room tray delivery: 13.32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding complaints about food taste and temperature, and meal service timing |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 23, 2024
Visit Reason
The inspection was conducted in response to a complaint regarding insufficient staffing to safely operate a Hoyer lift for resident transfers, specifically concerns about staff using only one person to operate the lift, resulting in resident bruising and safety issues.
Complaint Details
Complaint #73644 involved a family member reporting that staff used the Hoyer lift improperly by using only one person to transfer a resident, causing bruising. The complaint was substantiated by record reviews and interviews with residents, CNAs, and the Director of Nursing.
Findings
The facility failed to ensure adequate staffing to operate the Hoyer lift with two or more staff members as required, leading to residents being bumped, bruised, and experiencing frustration. Interviews with residents and staff confirmed that sometimes only one staff member operates the lift due to staffing shortages, despite training and physician orders requiring two-person assist.
Deficiencies (1)
Failed to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift, specifically insufficient staff to operate a Hoyer lift with two-person assist as required.
Report Facts
Residents reviewed for Hoyer lift usage: 3
Residents affected: 2
Date of physician order: Apr 30, 2024
Date care plan initiated: Jul 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Reported using Hoyer lift alone when unable to find help |
| CNA #4 | Certified Nursing Assistant | Reported always trying to use two staff members for Hoyer lift but sometimes difficult to find help |
| Director of Nursing | Director of Nursing | Confirmed staff training on Hoyer lift and acknowledged staffing challenges |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 20, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, activities programming, and diabetic management at Ladera Center.
Findings
The facility failed to maintain a homelike environment free from persistent urine odor, did not provide an activities program meeting residents' interests and preferences, and failed to properly monitor and notify physicians regarding residents' low blood sugar levels. These deficiencies posed risks of discomfort, psychosocial decline, and physical harm to residents.
Deficiencies (3)
Failed to provide a comfortable, homelike environment by not ensuring the hallway remained free of a persistent urine smell affecting 2 of 3 residents reviewed.
Failed to provide an activities program designed to meet the interests and preferences of each resident for 3 of 3 residents reviewed.
Failed to monitor blood sugar levels and notify the physician when a resident's blood sugar dropped below 70 mg/dL for 2 of 3 residents reviewed for diabetic management.
Report Facts
Residents reviewed for resident rights: 3
Residents affected by urine smell deficiency: 2
Residents reviewed for activities: 3
Residents affected by activities deficiency: 3
Residents reviewed for diabetic management: 3
Residents affected by diabetic management deficiency: 2
Blood sugar readings not documented: 9
Blood sugar reading: 57
Blood sugar reading: 66
Blood sugar reading: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager Registered Nurse | Unit Manager Registered Nurse (UMRN) | Interviewed regarding diabetic management and blood sugar monitoring deficiencies |
| Activities Assistant | Interviewed about activities program and scheduling issues | |
| Housekeeper | Interviewed about persistent urine smell in hallway |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 31, 2023
Visit Reason
The inspection was conducted following a complaint alleging resident-to-resident physical abuse involving multiple residents, and concerns about medication administration errors.
Complaint Details
The complaint submitted on 09/15/23 alleged that resident #3 was targeted and physically assaulted multiple times by resident #4 during smoking breaks. Interviews and record reviews confirmed repeated incidents of physical abuse. The facility also failed to protect residents from these altercations. Additionally, medication errors were identified for resident #11, who did not receive prescribed Eliquis, leading to worsening pulmonary embolism and immediate jeopardy.
Findings
The facility failed to prevent resident-to-resident physical abuse involving residents #3, #4, and #5, resulting in multiple incidents of physical altercations. Additionally, the facility failed to ensure medications were administered as ordered for resident #11, resulting in worsening pulmonary embolism and immediate jeopardy to resident health.
Deficiencies (2)
Failed to prevent resident-to-resident physical abuse and protect residents from physical altercations.
Failed to ensure medications were administered as ordered, resulting in worsening pulmonary embolism for resident #11.
Report Facts
Residents reviewed for abuse: 3
Residents affected by abuse deficiency: 2
Residents reviewed for medication: 3
Residents affected by medication deficiency: 1
Times resident #3 was hit by resident #4: 6
Dosage of Eliquis ordered: 5
Days resident #11 missed Eliquis: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Center Executive Director | Center Executive Director (CED) | Interviewed regarding resident #4 targeting resident #3 and facility interventions |
| Interim Director of Nursing | Interim Director of Nursing (DON) | Interviewed regarding behavioral contract appropriateness and medication reconciliation |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding psychiatric evaluation and resident cognitive status |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication reconciliation and immediate jeopardy corrective actions |
Inspection Report
Census: 116
Deficiencies: 20
Date: Sep 6, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, medication management, advance directives, privacy, grievance procedures, abuse prevention, restraint use, assessments, care planning, wound care, respiratory care, medication storage, nutrition, and dental services.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, informed consent for medications, safeguarding of medical records, maintaining a clean environment, proper grievance documentation, prevention of resident-to-resident abuse, restraint use, timely and accurate assessments and care plans, wound care management, respiratory care, medication management, food safety and handling, and dental care services.
Deficiencies (20)
Failed to ensure a resident was treated with dignity and respect when staff did not provide privacy during use of portable urinal.
Failed to ensure residents or guardians were aware of and understood risks and benefits of medications for unnecessary medications.
Failed to ensure a current copy of a resident's advance directive was present in the medical record.
Failed to safeguard clinical record information by leaving Protected Health Information unattended.
Failed to maintain a clean and sanitary dining area for residents.
Failed to ensure written grievance decisions included confirmation and resolution dates.
Failed to prevent resident to resident sexual abuse and protect residents from observing ongoing sexual behaviors and verbal abuse.
Failed to keep resident free from physical restraints when staff used geriatric chair as a side rail to keep resident from getting out of bed.
Failed to accurately complete Minimum Data Set assessments in a timely manner for residents.
Failed to develop and implement comprehensive person-centered care plans and revise care plans to address residents' needs.
Failed to follow physician's orders and document use of compression stockings for a resident.
Failed to provide quality wound care and monitoring for multiple residents, including failure to change dressings and use wound vac as ordered.
Failed to provide podiatry services and toenail care for a resident with diabetes and foot conditions.
Failed to ensure urine collection bags did not touch the floor for a resident with an indwelling urinary catheter.
Failed to provide sufficient fluid for hydration for a resident requiring assistance with drinking.
Failed to provide safe and appropriate respiratory care including proper dating and monitoring of oxygen tubing and humidifier bottles, ensuring oxygen delivery, and having physician orders for oxygen therapy.
Failed to provide a drug regimen free from unnecessary psychotropic medications by not responding to pharmacy recommendations for gradual dose reductions and reevaluations.
Failed to properly store medications in medication carts, document medication storage temperatures, and lock medication carts when unattended.
Failed to ensure a resident received dental services despite identified dental needs and care planning.
Failed to serve food according to menu, communicate menu changes, and follow dietary orders regarding food allergies.
Report Facts
Residents affected: 116
Residents affected: 25
Residents affected: 6
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 2
Residents affected: 6
Residents affected: 1
Residents affected: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Named in dignity and privacy deficiency for not closing door during resident's use of portable urinal |
| Center Executive Director | Interviewed regarding medication consent form alteration and resident grievances | |
| CNA #11 | Certified Nursing Assistant | Observed resident verbal abuse and sexual behavior, no intervention identified |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding advance directive documentation and wound care |
| Social Services Associate | Interviewed regarding advance directive documentation | |
| Medical Records | Interviewed regarding advance directive documentation | |
| Registered Nurse #2 | Registered Nurse | Observed leaving medication cart unlocked and computer unattended |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Interviewed regarding dining room cleanliness and food handling |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Interviewed regarding resident supervision and sexual behavior |
| Social Services Director | Interviewed regarding resident sexual behaviors and facility capability | |
| Center Executive Director | Interviewed regarding resident sexual behaviors and facility response | |
| Assistant Director of Nursing | Interviewed regarding restraint use, wound care, medication management, and psychotropic medication recommendations | |
| Director of Nursing | Interviewed regarding wound care, dialysis communication, respiratory care, and medication management | |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding use of Hoyer lift for resident transfers |
| Recreation Director | Interviewed regarding recreational activities and documentation | |
| Senior Director of Recreation | Interviewed regarding recreational activities and documentation | |
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Interviewed regarding urine collection bag placement |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Observed improper handling of bowls and cups during meal service |
| Certified Nursing Assistant #7 | Certified Nursing Assistant | Observed improper handling of glasses during meal service |
| Certified Nursing Assistant #8 | Certified Nursing Assistant | Observed improper handling of glasses during meal service |
| Unit Nursing Manager #2 | Interviewed regarding proper handling of bowls and cups | |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding medication storage temperature logs |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding wound care and wound vac orders |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Interviewed regarding resident supervision and sexual behavior |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding wound care and use of Hoyer lift |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding urine collection bag placement |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding wound care supplies and orders |
| Dietary Assistant | Interviewed regarding food storage and labeling | |
| Unit Nursing Manager #2 | Interviewed regarding proper handling of bowls and cups | |
| Scheduler | Interviewed regarding dental appointment scheduling |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 6, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide appropriate wound care and monitoring for multiple residents, including failure to follow physician orders and inadequate documentation of wound care treatments.
Complaint Details
The complaint investigation revealed substantiated deficiencies related to wound care for residents #29, 38, 61, 65, and 81. Immediate jeopardy was identified due to failure to provide wound care as ordered, missing wound vac orders, and inadequate documentation. The facility implemented a Plan of Removal including a whole house skin sweep and corrective actions.
Findings
The facility failed to provide appropriate wound care and monitoring for several residents, resulting in worsening wounds, lack of proper dressing changes, and missing physician orders for wound vacuums. Documentation of wound care was frequently missing or incomplete, and staff were unaware of or did not follow wound care orders. This failure posed immediate jeopardy to resident health and safety.
Deficiencies (1)
Failure to provide quality wound care and monitoring for 5 residents, including failure to follow physician orders and inadequate dressing changes.
Report Facts
Residents affected: 5
Dates with no wound care documentation: 16
Wound care documentation missing: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Mentioned as nurse responsible for wound vac progress note but did not enter wound vac order. |
| Director of Nursing | Director of Nursing (DON) | Unaware of missing wound vac orders and lack of staff oversight for wound care during wound nurse absences. |
| LPN #2 | Licensed Practical Nurse | Observed having difficulty locating wound care supplies and stated no orders for wound care for resident #29. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 23, 2023
Visit Reason
The inspection was conducted due to complaints alleging failure to notify a resident's Power of Attorney (POA) about a positive Covid-19 test and failure to complete thorough investigations and submit required 5-day follow-up reports for unwitnessed falls with injury involving residents.
Complaint Details
Complaint investigations involved allegations of failure to notify a resident's POA about Covid-19 positive status and failure to submit required 5-day follow-up reports for unwitnessed falls with injury. Complaints #63715 and #66026 were received by the State of New Mexico Health Department Complaints Department on 04/20/23 and 12/23/22 respectively. The facility did not submit the required follow-up reports.
Findings
The facility failed to notify a resident's POA when the resident tested positive for Covid-19, and failed to submit 5-day follow-up reports for two residents who had unwitnessed falls with injury. These deficiencies could prevent timely family notification and hinder proper investigation and corrective actions for abuse and neglect.
Deficiencies (2)
Failed to notify a resident's POA when a resident tested positive for Covid-19.
Failed to complete thorough investigations and submit 5-day follow-up reports for allegations of unwitnessed falls with injury for two residents.
Report Facts
Residents reviewed for change in condition: 3
Residents reviewed for neglect: 3
Residents affected by failure to notify POA: 1
Residents affected by failure to submit 5-day follow-up report: 2
Dates of positive Covid-19 test: Feb 27, 2023
Dates of falls with injury: Apr 11, 2023
Dates of falls with injury: Dec 22, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Co-Director of Nursing | Stated expectation that family representatives are notified the same day a resident tests positive for Covid-19 | |
| Administrator | Provided COVID-19 positive residents log and reportable incidents list; verified lack of 5-day follow-up reports | |
| Social Services Director | Received complaint from resident's POA regarding lack of notification of Covid-19 positive test |
Inspection Report
Deficiencies: 1
Date: Feb 17, 2023
Visit Reason
The inspection was conducted to review compliance with regulations regarding residents' rights to request, refuse, or discontinue treatment, participate in or refuse experimental research, and to formulate advance directives.
Findings
The facility failed to ensure that 2 of 5 residents' Advanced Directive forms (MOST forms) were signed by a physician as required, potentially affecting residents' end-of-life medical choices and causing unnecessary suffering.
Deficiencies (1)
Failure to ensure that Advanced Directive (MOST) forms for residents #1 and #4 were signed by a physician as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the signing process and timing of MOST forms by physicians. |
Inspection Report
Routine
Deficiencies: 17
Date: Jun 1, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, safety, infection control, medication management, and facility operations.
Findings
The facility was found deficient in multiple areas including call light accessibility, resident bathing preferences, unresolved resident grievances, incomplete survey report postings, inaccurate advance directives, restroom cleanliness, delayed baseline care plans, incomplete care plan meetings, inadequate hygiene assistance, urinary catheter care, oxygen administration without orders, pain management, infection control practices, food safety and sanitation, medical record accuracy, and COVID-19 testing compliance.
Deficiencies (17)
Failed to ensure call light was within reach for residents sharing a restroom.
Failed to ensure residents were bathed according to their preferences.
Failed to ensure grievances identified by the Resident Council were resolved and communicated.
Failed to have survey reports for the previous three years readily accessible to residents and visitors.
Failed to ensure accurate and well documented Advance Directives in residents' medical records.
Failed to ensure restroom was clean and housekeeping maintained sanitary conditions.
Failed to develop a baseline care plan within 48 hours of admission for a resident with a tracheostomy.
Failed to maintain a process for scheduling care plan meetings for residents.
Failed to provide hygiene needs for a resident requiring bathing assistance.
Failed to provide quality urinary catheter care for a resident showing signs of decline.
Administered oxygen without a physician's order, care plan, and with inconsistent documentation.
Failed to adequately maintain and control a resident's pain, resulting in refusal of care.
Failed to provide necessary behavioral health care and services to a resident with behavioral concerns.
Failed to ensure food was prepared and stored in accordance with professional standards including temperature monitoring, sanitization, labeling, and cleaning.
Failed to ensure medical records and Minimum Data Set were complete and accurate for a resident on unnecessary medications.
Failed to provide and implement an effective infection prevention and control program including proper PPE use, hand hygiene, and timely COVID testing.
Failed to ensure all staff were tested twice weekly for COVID-19 during an outbreak.
Report Facts
Deficiencies cited: 17
Residents affected: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #8 | Certified Nurse Aide | Confirmed call light cord should not be tied around the rail. |
| Director of Nursing | Director of Nursing | Confirmed call light cord should not be wrapped around the rail and residents should be able to reach and trigger the alarm. |
| Certified Nursing Executive | Certified Nursing Executive | Commented on shower documentation issues and resident pain management. |
| Unit Manager #1 | Unit Manager | Discussed shower documentation and resident care plan meetings. |
| CNA #4 | Certified Nurse Assistant | Provided information on shower frequency and documentation. |
| Medical Records staff member (MR #1) | Medical Records Staff | Confirmed lack of advanced directive for resident and discrepancies in documentation. |
| Housekeeper #1 | Housekeeper | Reported on restroom cleaning issues. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Discussed resident falls and pain management. |
| Certified Nurse Assistant #3 | Certified Nurse Assistant | Confirmed resident hygiene needs and shower frequency. |
| Nurse Practitioner #1 | Nurse Practitioner | Ordered catheter change and urinalysis for resident. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed oxygen concentrator issues and lack of physician order. |
| Center Nurse Executive | Center Nurse Executive | Discussed oxygen orders and psychiatric care. |
| Social Services Director | Social Services Director | Discussed care plan meetings and resident appointments. |
| Laboratory Technician | Laboratory Technician | Discussed COVID testing procedures and symptom identification. |
| Infection Preventionist Coordinator | Infection Preventionist Coordinator | Discussed PPE use and COVID testing compliance. |
| Kitchen Aide #3 | Kitchen Aide | Discussed food temperature logging and cleaning. |
| Maintenance Technician #1 | Maintenance Technician | Confirmed ice machine cleaning schedule. |
| Lab Tech | Laboratory Technician | Discussed COVID testing of staff and residents. |
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