Inspection Reports for
Laverna Manor Health & Rehabilitation
904 SOUTH HALL AVE, SAVANNAH, MO, 64485-1952
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
17.5 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
218% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
46% occupied
Based on a December 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 3
Date: Dec 12, 2025
Visit Reason
The inspection was conducted due to complaints regarding missing fentanyl patches for two residents and a fall incident involving a mechanical lift causing injury to another resident.
Complaint Details
The investigation was triggered by complaints about missing fentanyl patches for Residents #2 and #3, and a fall incident involving Resident #1 from a mechanical lift. The patches were unaccounted for and no proper investigation was conducted. Resident #1 was not sent to the hospital as ordered after the fall, and the resident fell due to improper sling attachment during transfer.
Findings
The facility failed to ensure proper investigation and accounting for missing fentanyl patches for two residents, and failed to follow physician orders to send a resident to the hospital after a fall from a mechanical lift. Additionally, the facility failed to ensure safe transfer procedures, resulting in a resident falling from a mechanical lift causing pain and injury.
Deficiencies (3)
Failed to ensure residents were free from misappropriation of fentanyl patches and failed to conduct proper investigations for missing patches.
Failed to follow physician's orders to send a resident to the hospital for x-rays after a fall from a mechanical lift.
Failed to properly transfer a resident using a mechanical lift, resulting in the resident falling and sustaining pain to shoulders and left hip.
Report Facts
Facility census: 55
Fentanyl patch dosage: 12
Fall height: 4
Hydrocodone-Acetaminophen dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Reported missing fentanyl patch for Resident #2 and assessed Resident #1 after fall |
| Director of Nursing | Director of Nursing (DON) | Notified of missing fentanyl patches and fall incident; did not conduct investigation |
| Primary Care Physician A | Primary Care Physician | Ordered hospital evaluation after Resident #1 fall; disagreed with facility decision to use mobile x-rays |
| Administrator | Facility Administrator | Informed staff to use mobile x-rays instead of hospital for Resident #1; expected investigations for missing patches |
| CNA A | Certified Nurse Aide | Assisted in transfer of Resident #1 during fall incident |
| CNA B | Certified Nurse Aide | Assisted in transfer of Resident #1 during fall incident |
| Medical Director | Medical Director | Expected notification of missing narcotics and adherence to physician orders |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Jun 13, 2025
Visit Reason
The inspection was conducted due to a complaint or allegation regarding the misappropriation of a resident's narcotic medications at the facility.
Complaint Details
The complaint investigation found no allegation as to why the investigation was prompted, no alleged perpetrator identified, and local police were contacted. The investigation revealed lack of proper inventory controls and that the missing drugs were most likely taken by a staff member.
Findings
The facility failed to ensure one resident was free from misappropriation of narcotic medications, with approximately 60 pills of Oxycodone 5mg missing. The investigation was inconclusive, with no perpetrator identified, and revealed inadequate inventory controls over controlled substances.
Deficiencies (1)
Failure to protect a resident from misappropriation of narcotic medications.
Report Facts
Residents affected: 1
Census: 58
Missing medication count: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Interviewed regarding medication counts and narcotic inventory procedures |
| Administrator | Facility Administrator | Interviewed regarding previous and current medication inventory processes |
| Police Officer A | Police Officer | Conducted preliminary investigation and stated evidence indicated staff involvement |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Date: May 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a sexual abuse incident where one resident (Resident #2) inappropriately touched another resident (Resident #1) in the memory care unit.
Complaint Details
The complaint investigation was substantiated. The incident occurred on 4/14/25 when Resident #2 ran his/her hand up Resident #1's thighs and grabbed the genital area. Both residents had severely impaired cognition and could not provide information. The facility took immediate corrective actions including 1:1 supervision and medication adjustments.
Findings
The facility failed to keep Resident #1 safe from sexual abuse by Resident #2. Upon discovery, the facility immediately separated the residents, assessed them with no injuries found, placed Resident #2 on 1:1 supervision, initiated abuse training for staff, and adjusted Resident #2's medications. The noncompliance was corrected within three days.
Deficiencies (1)
Failure to protect a resident from sexual abuse by another resident.
Report Facts
Residents present: 61
Date of incident: Apr 14, 2025
Date noncompliance corrected: Apr 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Observed the abuse incident and notified charge nurse |
| Director of Nursing | Interviewed regarding immediate actions taken after the incident | |
| Administrator | Interviewed regarding follow-up actions and family communication |
Inspection Report
Plan of Correction
Census: 73
Deficiencies: 1
Date: Oct 30, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction following a survey completed on 10/30/2024 at Laverna Manor Health & Rehabilitation.
Findings
The facility failed to provide personal funds and a final accounting within thirty days upon discharge for four sampled residents. Refund requests for some residents were delayed beyond the required timeframe, resulting in a violation.
Deficiencies (1)
19 CSR 30-88.020(12) requires providing an account of funds to fiduciary. The facility failed to provide personal funds and a final accounting within thirty days upon discharge for four sampled residents.
Report Facts
Facility census: 73
Resident refund balances: 2315.95
Resident refund balances: 1777.01
Resident refund balances: 100
Resident refund balances: 1000
Refund request amount: 2315.94
Refund request amount: 1777.01
Refund request amount: 1150
Refund request amount: 1000
Resident overpaid amount: 1050
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding refund requests and resident accounts | |
| Administrator | Interviewed regarding refund timelines |
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 5
Date: Oct 10, 2024
Visit Reason
A recertification and complaint survey was conducted to assess compliance with federal regulations and investigate a complaint of resident abuse and neglect.
Complaint Details
The complaint investigation was substantiated based on interviews, record reviews, and policy review confirming resident-to-resident abuse occurred and was not properly prevented or documented.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies were cited related to freedom from abuse and neglect, notice requirements before transfer or discharge, notice of bed hold policy, quarterly assessments, and accuracy of assessments.
Deficiencies (5)
F600: The facility failed to protect residents from physical abuse, as evidenced by an incident involving resident-to-resident altercation that was substantiated.
F623: The facility failed to provide written notice of transfer or discharge to residents and their representatives as required by regulation.
F625: The facility failed to provide written notice of bed hold policy and return to residents or their representatives before transfer or discharge.
F638: The facility failed to ensure quarterly Minimum Data Set assessments were completed and submitted timely for one resident.
F641: The facility failed to ensure accuracy of assessments, including coding of anticoagulant therapy and smoking status for residents.
Report Facts
Survey Census: 57
Sample Size: 23
Supplemental Residents: 10
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 5
Date: Oct 10, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to protect a resident from physical abuse by another resident, failure to provide timely written transfer/discharge notices, failure to provide written bed hold notices, failure to complete quarterly Minimum Data Set (MDS) assessments, and failure to ensure accurate MDS assessments.
Complaint Details
The complaint investigation was substantiated. Resident R23, with a history of hitting another resident, hit resident R42 unprovoked on 09/28/24. The facility confirmed the incident and placed R23 on 1:1 supervision until psychiatric evaluation and discharge.
Findings
The facility failed to protect a resident from physical abuse by another resident, failed to provide written transfer/discharge and bed hold notices to residents transferred to the hospital, failed to complete and submit a quarterly MDS assessment for one resident, and failed to ensure accurate MDS assessments for five residents. The abuse allegation was substantiated and the facility census was 57.
Deficiencies (5)
Failed to protect resident R42 from physical abuse by resident R23.
Failed to provide timely written transfer/discharge notices to residents R29 and R61.
Failed to provide written bed hold notices to residents R29 and R61.
Failed to complete and submit quarterly MDS assessment for resident R14.
Failed to ensure accurate MDS assessments for residents R37, R29, R30, R34, and R57 due to incorrect coding of medications and tobacco use.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 5
Facility census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hospitality Aide 1 | Hospitality Aide | Witnessed and reported the abuse incident between residents R23 and R42 |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Assessed residents after abuse incident but failed to document assessment |
| Director of Nursing | Director of Nursing | Was notified of abuse incident but was out of town; confirmed use of RAI Manual for assessments |
| Administrator | Administrator | Handled investigation of abuse incident and confirmed substantiation |
| RN1 | Registered Nurse | Described emergent transfer process and provision of notices |
| Social Services Director | Social Services Director | Reviewed transfer and bed hold notices and confirmed lack of documentation |
| MDS Coordinator | MDS Coordinator | Acknowledged missed submission of quarterly MDS and inaccurate coding of medications |
Inspection Report
Life Safety
Census: 57
Capacity: 120
Deficiencies: 1
Date: Oct 8, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and participation requirements for Medicare/Medicaid.
Findings
The facility was found to be noncompliant with fire safety requirements due to deficiencies in stairway door assemblies and fire exit hardware. The deficient practices had the potential to affect all 57 residents present during the survey.
Deficiencies (1)
K311: The facility failed to ensure one out of four stairway door assemblies were fire rated and one stairway exit door was not equipped with approved fire exit hardware as required by NFPA 101 Life Safety Code.
Report Facts
Occupied beds: 57
Total licensed beds: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed deficiencies related to stairway door fire rating and hardware |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Jul 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a cognitively impaired resident with a known elopement risk who eloped from the facility and sustained injuries.
Complaint Details
The complaint investigation found the violation to be at an imminent danger class I level. The resident eloped multiple times, sustained serious injuries including fractures, and the facility failed to implement adequate supervision and safety measures. The violation severity was lowered to class II at exit.
Findings
The facility failed to provide adequate supervision and assistance devices to prevent accidents and elopement for a high-risk resident. The resident eloped multiple times, sustained fractures, and the facility did not secure windows or provide continuous one-on-one supervision as required.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision and assistance devices to prevent accidents and elopement for a cognitively impaired resident with a known elopement risk. The resident eloped multiple times, sustained fractures, and the facility did not secure windows or provide continuous one-on-one supervision.
A4074 19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave: The facility failed to provide twenty-four-hour protective oversight and supervision for residents on voluntary leave, contributing to an imminent danger situation for the resident.
Report Facts
Facility census: 58
Resident elopement risk score: 18
Resident fall risk score: 8
Number of skin tears: 3
Measurement of window to ground: 6
Measurement of window to grass: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gwen M. Martin | Laboratory Director or Provider/Supplier Representative | Signed the statement of deficiency |
| LPN B | Licensed Practical Nurse | Interviewed regarding resident admission and elopement events |
| LPN C | Licensed Practical Nurse | Interviewed regarding resident exit seeking and elopement |
| Certified Medication Technician C | CMT | Interviewed about resident behavior and medication administration |
| Certified Nurse Aide B | CNA | Interviewed about resident exit seeking and elopement |
| Certified Nurse Aide C | CNA | Interviewed about resident supervision and elopement |
| Certified Nurse Aide E | CNA | Interviewed about resident supervision and injuries |
| Registered Nurse | RN | Documented resident transport to Emergency Room |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 3
Date: Apr 30, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with nutritional and food safety standards, including menu preparation, food palatability, temperature control, and food service safety.
Findings
The facility failed to ensure menus were prepared in advance and posted, residents were not offered menu choices, food was not served at safe and appetizing temperatures, and food service safety standards were not met, including failure to maintain proper food temperatures and sanitation practices during food distribution.
Deficiencies (3)
Menus were not prepared in advance, not posted, residents not offered menu choices, and alternatives not posted.
Food served was not palatable, attractive, or at a safe and appetizing temperature; meat was too hard to cut; condiments not offered.
Failed to maintain food temperatures during distribution, did not temperature check foods after reheating, failed to cover foods during transport, reused meal trays improperly, and failed to check dishwashing temperatures.
Report Facts
Residents affected: 3
Residents affected: 5
Census: 58
Inspection Report
Re-Inspection
Census: 74
Deficiencies: 13
Date: Mar 25, 2024
Visit Reason
The inspection was conducted as a re-inspection to verify correction of previously cited deficiencies related to resident dignity and privacy, and food service issues.
Findings
The facility was found deficient in ensuring residents were treated with respect and dignity, specifically regarding the use of Styrofoam and plastic cutlery for meals. Additionally, deficiencies were noted in menu planning, food preparation, and food service safety, including failure to meet nutritional needs and maintain proper food temperatures.
Deficiencies (13)
F557 Respect, Dignity/Right to have Personal Property. The facility failed to ensure residents were treated with respect and dignity by serving meals with plastic cutlery and Styrofoam plates for three sampled residents.
A8030 Dignity/Privacy. The facility did not fully protect residents' privacy and dignity during treatment and care.
F803 Menus Meet Resident Needs/Prepared in Advance/Followed. The facility failed to ensure menus were prepared in advance, posted, and offered alternatives, affecting three of five sampled residents.
F804 Nutritive Value/Appearance/Palatable/Preferred Temperature. The facility failed to serve food that was palatable, attractive, and at safe temperatures, with issues including cold food and hard meat affecting multiple residents.
A5003 Foods-Nutritive Value/Flavor/Appearance. Foods were not prepared and served to conserve nutritive value, flavor, and appearance.
A5005 Hot Food Hot, Cold Food Cold. The facility failed to assure hot food was served hot and cold food served cold.
A5021 Menus Plan/Post/Keep, List Substitutes. Menus were not properly planned, posted, or substituted as required.
A7015 Food-Protected, Temp, Need to Contact DHSS. Food was not protected from contamination and temperature hazards.
A7016 Food Clean Containers, Storage, Covers. Food was not stored in clean, covered containers during preparation and service.
A7025 Hot Food-Storage, Temperatures. Hot food storage facilities did not maintain required temperatures.
A7026 Hot Food-140 Degrees or Above/Transport. Hot food was not maintained at required temperatures during transport.
A7036 Food-120 Degrees/Above, 45 Degrees/Below. Food was not served at proper temperatures during service.
A7063 Tableware Clean/Sanitize. Tableware was not properly washed, rinsed, and sanitized after use.
Report Facts
Facility census: 74
Facility census: 58
Temperature: 120
Temperature: 117.1
Temperature: 110.7
Temperature: 155
Temperature: 126
Temperature: 163.1
Temperature: 195.8
Temperature: 176.1
Temperature: 154.8
Temperature: 192.4
Temperature: 165
Temperature: 189
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Marshall | Administrator | Signed multiple inspection and plan of correction documents |
Inspection Report
Routine
Census: 74
Deficiencies: 6
Date: Mar 25, 2024
Visit Reason
The inspection was conducted to assess compliance with resident dignity and respect, menu preparation and choice, food palatability and temperature, and food safety standards at the facility.
Findings
The facility failed to ensure residents were treated with dignity during meal service by using plastic cutlery and Styrofoam plates for an extended period. Menus were not prepared or posted in advance, limiting resident choice. Food was often served cold or at unsafe temperatures, and condiments were not consistently offered. Food safety practices were deficient, including failure to maintain proper food temperatures during transport and service, reuse of un-sanitized trays, and incomplete dishwasher temperature logs.
Deficiencies (6)
Failure to provide dignified dining experience using appropriate dishware and utensils.
Menus were not prepared in advance, not posted, and alternatives were not offered or posted.
Food served was not palatable, attractive, or at safe and appetizing temperatures; condiments not offered as appropriate.
Failure to maintain food temperatures during distribution and service; food temperatures below safe levels.
Reuse of un-sanitized meal trays for serving multiple residents, risking cross contamination.
Dishwasher temperature logs were incomplete and not consistently recorded as required.
Report Facts
Facility census: 74
Facility census: 58
Food temperature: 120
Food temperature: 117.1
Food temperature: 110.7
Dishwasher temperature: 189
Dishwasher temperature log frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Provided multiple interviews regarding food temperatures, menu posting, and food service practices | |
| Certified Nurse Aide (CNA) A | Interviewed regarding meal service, food temperature complaints, and tray handling | |
| Certified Nurse Aide (CNA) B | Interviewed regarding meal service, food temperature complaints, and tray handling | |
| Certified Nurse Aide (CNA) C | Interviewed regarding meal ticket system and food service practices | |
| Administrator | Interviewed regarding dishwasher use, food temperature expectations, and resident complaints | |
| Dietary Aide [NAME] A | Observed transporting food carts and serving meals; involved in incidents of dropped meal tickets and tray reuse |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 2
Date: Jul 5, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident care, specifically focusing on the frequency and quality of meals and snacks provided to residents.
Findings
The facility failed to provide night time snacks to residents according to their preferences and needs, affecting three sampled residents. Interviews and record reviews confirmed that snacks were not consistently offered, and dietary staff were not ordering or providing adequate snacks.
Deficiencies (2)
F809 Frequency of Meals/Snacks at Bedtime: The facility did not honor resident choices for night time snacks, failing to provide suitable nourishing snacks at non-traditional times consistent with resident preferences and plans of care. This affected three sampled residents.
A5007 Bedtime Snacks, Offered/Nourishing: Bedtime snacks of nourishing quality were not offered to all residents unless medically contraindicated, violating 19 CSR 30-85.052(7).
Report Facts
Facility census: 60
Number of sampled residents affected: 3
Inspection Report
Census: 60
Deficiencies: 1
Date: Jul 5, 2023
Visit Reason
The inspection was conducted to assess compliance with resident nutritional needs, specifically regarding the provision of meals and snacks according to resident preferences and requests.
Findings
The facility failed to provide night time snacks according to resident preferences, affecting three sampled residents. Interviews and record reviews revealed that snacks had not been consistently offered for two to four months, with limited snack options and budget constraints cited as contributing factors.
Deficiencies (1)
Failure to honor resident choices by not offering night time snacks according to preferences.
Report Facts
Residents affected: 3
Facility census: 60
Duration of issue: 3
Inspection Report
Routine
Census: 62
Deficiencies: 4
Date: Mar 14, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with physician orders regarding weekly weights and nutritional interventions for residents, specifically addressing concerns about unplanned weight loss in several residents.
Findings
The facility failed to ensure weekly weights were obtained and interventions implemented for three of four residents to maintain nutritional status and prevent significant weight loss. The facility lacked a policy on nutrition and unplanned weight loss, and care plans did not adequately address weight loss risks or interventions. Staff and administration were unaware of some residents' weight loss issues.
Deficiencies (4)
Failure to follow physician's orders to obtain weekly weights and implement interventions for residents to maintain nutritional status and prevent significant weight loss.
Facility did not provide a policy on nutrition and/or unplanned weight loss.
Care plans lacked interventions addressing residents' current weight loss or risk for weight changes.
Staff and administration were not aware of residents with weight loss and did not consistently notify appropriate personnel or update care plans accordingly.
Report Facts
Weight loss: 13
Weight loss: 13.7
Weight loss: 7.2
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Interviewed regarding weighing procedures and notification process for weight changes. |
| ADN | Assistant Director of Nursing | Interviewed about monitoring resident weights and notification of physicians for weight loss. |
| MDS coordinator | Responsible for care planning weight loss and nutrition interventions; interviewed about awareness of residents' weight loss. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed about notification and care planning for residents with weight loss. |
| Administrator | Administrator | Interviewed about notification and plans for residents with weight loss. |
Inspection Report
Abbreviated Survey
Census: 57
Deficiencies: 8
Date: Feb 10, 2023
Visit Reason
The abbreviated survey was conducted due to an Immediate Jeopardy (IJ) situation related to abuse and neglect involving a resident's privacy violation via unauthorized video recording and posting on social media.
Complaint Details
The visit was complaint-related due to an Immediate Jeopardy involving abuse when a staff member recorded and posted a video of a resident naked in the shower without consent. The complaint was substantiated as the facility failed to protect the resident's privacy and prevent abuse.
Findings
The facility failed to keep one resident free from abuse when a staff member used a cell phone to record and post a video of the resident naked in the shower without consent. The facility also failed to ensure nursing staff had appropriate competencies and training, and nurse aides were not properly trained or documented. The Immediate Jeopardy was removed during the survey, and corrective actions were implemented.
Deficiencies (8)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to keep one resident free from abuse when a staff member recorded and posted a video of the resident naked in the shower without consent.
F726 Competent Nursing Staff: The facility failed to ensure nursing staff had appropriate competencies and skills to provide safe and effective care, as evidenced by lack of training and documentation for nurse aides.
A4022 Employee Orientation/Continuing Education: The facility did not provide adequate in-service orientation and continuing education for all personnel, including infection control and emergency protocols.
A4023 NA Training Complete in 4 Months: Nursing assistants did not complete the required training and certification within four months of employment.
A8022 Free From Abuse: Each resident shall be free from abuse including verbal, physical, sexual, or emotional abuse. The facility failed to prevent abuse as referenced in F600.
F692 Nutrition/Hydration Status Maintenance: The facility failed to ensure residents maintained acceptable nutritional status and followed physician orders for weekly weights and interventions for weight loss.
A5001 Nutritional Needs Met, Assess Resident, Inform Doctor: The facility failed to meet nutritional needs and properly assess residents, as evidenced by weight loss and lack of adequate interventions.
F728 Facility Hiring and Use of Nurse Aide: The facility failed to ensure nurse aides met minimum qualifications, training, and competency evaluation requirements.
Report Facts
Facility census: 57
Facility census: 56
Facility census: 57
Facility census: 62
Weight loss percentage: 8.8
Weight loss percentage: 7.7
Weight loss percentage: 6.2
Inspection Report
Plan of Correction
Census: 56
Deficiencies: 1
Date: Jan 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding personal clothing and possessions inventory at Laverna Senior Living.
Findings
The facility failed to maintain a record of personal possessions for four sampled residents. Interviews revealed staff uncertainty about responsibility for inventory, and prior to electronic records, paper checklists were inconsistently completed.
Deficiencies (1)
19 CSR 30-88.010(36) Personal Clothing/Possessions: The facility failed to maintain a record of personal possessions for four of four sampled residents. Staff interviews confirmed no inventory was completed or responsibility assigned.
Report Facts
Facility census: 56
Residents sampled: 4
Inspection Report
Routine
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and relevant federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Routine
Census: 59
Deficiencies: 20
Date: Aug 25, 2022
Visit Reason
Routine inspection of Laverna Manor Health & Rehabilitation to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, medication management, infection control, staffing, activities programming, food safety, pressure ulcer care, and quality assurance processes. Specific issues included failure to provide adequate personal care and activities, medication errors, expired and unlabeled medications, lack of RN coverage, inadequate infection preventionist designation, and failure to maintain a clean kitchen environment.
Deficiencies (20)
Failure to treat residents with dignity and respect, including inadequate personal hygiene, grooming, and resident rights.
Failure to properly manage resident trust funds, including failure to refund balances timely and maintain appropriate bonds.
Failure to provide required notices for Medicare non-coverage to residents discharged from skilled nursing services.
Use of physical restraints without proper documentation and inappropriate use of four-point restraints to hold a resident during care.
Failure to provide timely transfer/discharge notifications and bed-hold notices to residents and responsible parties.
Failure to follow professional standards in medication administration including lack of orders for blood sugar checks, improper insulin injection technique, and improper administration of eye and nasal sprays.
Failure to provide adequate personal care including incomplete perineal care and inconsistent showering.
Failure to provide safe and appropriate respiratory care including lack of oxygen orders and failure to clean oxygen equipment.
Failure to maintain RN coverage for at least eight consecutive hours per day, seven days a week.
Employment of nurse aides under 18 years old and failure to ensure nurse aides complete required training within 120 days.
Failure to provide necessary behavioral health care and services to a resident with dementia and behavioral disturbances.
Failure to ensure monthly pharmacy drug regimen reviews for residents.
Medication error rate of 20% due to improper insulin administration and other medication errors.
Failure to properly label and discard expired medications and biologicals, and failure to maintain medication storage areas properly.
Failure to serve food at safe temperatures and maintain kitchen and food storage areas in a sanitary condition.
Failure to provide nourishing snacks at bedtime and document snack distribution and acceptance.
Failure to maintain a coordinated plan of care with hospice providers and ensure resident needs are met.
Failure to maintain an effective Quality Assessment and Assurance (QAA) program including lack of meetings and corrective action plans.
Failure to designate a qualified infection preventionist responsible for the infection prevention and control program.
Failure to implement an antibiotic stewardship program to monitor and manage antibiotic use.
Report Facts
Medication errors: 5
Resident census: 59
Fall risk score: 16
Fall risk score: 10
Fall risk score: 14
Braden score: 12
Medication count missing signatures: 8
Temperature range: 32
Temperature range: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication administration errors and oxygen equipment observations. |
| CNA D | Certified Nurse Aide | Named in perineal care deficiencies and medication administration observations. |
| CNA E | Certified Nurse Aide | Named in pressure ulcer care and resident behavior incident. |
| Administrator | Interviewed regarding staffing, QAPI, and facility operations. | |
| Clinical Services Director | Interviewed regarding staffing, medication management, and resident care. | |
| Dietary Aide A | Interviewed regarding food preparation and serving practices. | |
| Activity Director | Interviewed regarding activities programming deficiencies. | |
| LPN B | Licensed Practical Nurse | Named in medication storage and treatment observations. |
| CMT A | Certified Medication Technician | Named in medication administration observations. |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
Date: Feb 17, 2022
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted on 2/8/22 and 2/9/22 to assess compliance with CMS and CDC recommended practices for COVID-19 preparedness.
Complaint Details
The visit was complaint-related, triggered by concerns about resident falls and infection control practices. The report does not explicitly state substantiation status but documents deficiencies found.
Findings
The facility was found not in compliance with requirements related to accident hazards and infection prevention and control. Specifically, the facility failed to ensure residents remained safe from accident hazards, as two residents fell without proper investigation or care plan updates. Additionally, the facility failed to maintain an effective infection prevention and control program, including COVID-19 screening and staff compliance.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure residents remained safe from accident hazards as two residents fell and staff did not update care plans or perform fall investigations. The facility census was 66.
F880 Infection Prevention & Control: The facility failed to maintain an infection prevention and control program, including failure to screen staff for COVID-19 symptoms before duty and incomplete COVID-19 screening questionnaires. The facility census was 66.
Report Facts
Facility census: 66
Residents affected by falls: 2
Residents sampled: 3
Residents on special care unit: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Young | Administrator | Signed the plan of correction and mentioned in interviews regarding fall investigations and infection control |
| Director of Nursing | Director of Nursing (DON) | Documented resident conditions and was involved in fall incident documentation and infection control training |
| LPN A | Licensed Practical Nurse | Documented resident conditions and care related to falls |
| LPN B | Licensed Practical Nurse | Documented resident fall and injury |
| LPN C | Licensed Practical Nurse | Documented communication with hospital and resident care |
| Certified Nurse's Aide (CNA) C | Certified Nurse's Aide | Found resident after fall and assisted with care |
| Certified Nurse's Aide (CNA) D | Certified Nurse's Aide | Witnessed resident fall and reported to nurse |
| RN A | Registered Nurse | Interviewed about resident fall and care |
| Care Plan Coordinator | Care Plan Coordinator | Responsible for updating resident care plans |
Inspection Report
Plan of Correction
Census: 68
Deficiencies: 12
Date: Feb 9, 2022
Visit Reason
The document is a Plan of Correction submitted by LaVerna Senior Living following a survey conducted on 02/09/2022. It addresses deficiencies cited during the inspection related to resident care, nutrition, and facility operations.
Findings
The facility was found deficient in providing adequate personal care such as biweekly showers and changing bed linens, following menus and nutritional adequacy, accommodating resident food preferences, and maintaining food safety and pest control. Multiple residents were affected by these deficiencies.
Deficiencies (12)
F677: The facility failed to ensure staff offered residents biweekly showers and changed bed linens as scheduled, affecting five sampled residents. Observations and interviews showed residents had infrequent showers and unclean linens.
F803: The facility failed to follow menus provided by the Registered Dietician and lacked proper ingredients to prepare meals, affecting all residents. Observations showed missing menu items, cold meals, and late service.
F806: The facility failed to accommodate resident allergies, preferences, and substitutes on the special care unit. Observations showed all residents received the same meal without choice, and staff did not inquire about preferences.
F809: The facility failed to provide a policy on meal frequency and bedtime snacks, resulting in late meals and residents not receiving snacks. Observations and interviews confirmed inconsistent meal service and lack of snacks.
F812: The facility failed to maintain food safety and pest control, including storing food properly and checking for pests. Observations showed dirty dishes, mouse droppings, and expired food in the kitchen and storeroom.
A4076: The facility failed to ensure residents were clean, dry, and odor free, linked to the F677 deficiency. Residents were observed with greasy hair and unclean linens.
A5006: The facility failed to offer appropriate substitutes for refused food, linked to F806. Residents were not provided meal choices on the special care unit.
A5010: The facility failed to establish a meal schedule with appropriate time intervals between meals, linked to F809. Meals were served late and residents missed bedtime snacks.
A5016: The facility failed to review and approve special prescribed diets by qualified personnel, linked to F803. Menus were not followed and ingredients were missing.
A6039: The facility failed to implement effective rodent control measures, linked to F812. Evidence of mice was found in the kitchen and storeroom.
A7016: The facility failed to properly store food in clean covered containers and maintain food-contact surfaces, linked to F812. Dirty dishes and uncovered food were observed.
A7065: The facility failed to wash, rinse, and sanitize food-contact surfaces at required intervals, linked to F812. Dirty dishes and unsanitary conditions were noted.
Report Facts
Facility census: 68
Deficiencies cited: 12
Plan of correction completion date: Mar 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Young | Administrator | Signed the plan of correction and mentioned in interviews regarding shower scheduling |
| Director of Nursing | Mentioned in interviews about scheduling resident showers and meal service issues | |
| Certified Nurse Assistant (CNA) E | Certified Nurse Assistant | Interviewed regarding shower scheduling and sheet changing responsibilities |
| Certified Nurse Assistant (CNA) F | Certified Nurse Assistant | Interviewed about sheet changing on the special care unit |
| Dietary Manager | Dietary Manager | Interviewed about dietary concerns and meal service issues |
| District Dietary Manager | District Dietary Manager | Interviewed about facility staffing and food service problems |
| Registered Dietitian | Registered Dietitian | Interviewed about meal preferences and menu compliance |
| Cook A | Cook | Interviewed about meal preparation and staffing |
| Certified Nurse Assistant (CNA) A | Certified Nurse Assistant | Interviewed about dietary staff serving meals on the special care unit |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed about dietary staff serving meals on the special care unit |
| Activity Director | Activity Director | Interviewed about food issues reviewed at resident council meetings |
| Maintenance Supervisor | Maintenance Supervisor | Mentioned regarding pest control notifications |
Inspection Report
Routine
Deficiencies: 0
Date: Feb 10, 2021
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices and relevant federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from November 10 to November 23, 2020, to assess the facility's compliance with related CMS and CDC requirements.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
A COVID-19 focused infection control survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control. A subsequent COVID-19 focused emergency preparedness survey also found the facility in compliance with relevant federal regulations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from May 20 to May 28, 2020 to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
Date: Jan 8, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of resident property at Laverna Senior Living.
Complaint Details
The complaint was substantiated as the facility failed to prevent misappropriation of resident property by an employee. The resident's ID, credit card, and debit card were found in the employee's possession. The employee was terminated and corrective actions were implemented.
Findings
The facility failed to prevent the misappropriation of one resident's identification, credit card, and debit card by an employee. The issue was investigated, and corrective actions were taken including staff training and termination of the responsible employee.
Deficiencies (1)
F 602: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility failed to prevent misappropriation of one resident's ID, credit card, and debit card by an employee, which was discovered during a police investigation.
Report Facts
Facility census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in misappropriation of resident property finding and termination |
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 10
Date: Dec 13, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for LaVerna Senior Living facility.
Findings
The facility was found deficient in multiple areas including resident rights and dignity during meal service, advance directives documentation, medication administration, infection control, quality of care, and safety measures. Several residents were affected by these deficiencies.
Deficiencies (10)
F550 Resident Rights: The facility failed to ensure staff treated residents with dignity and respect during meal service, including privacy and assistance with eating. This affected multiple residents and was evidenced by observations and interviews.
F578 Advance Directives: The facility failed to ensure staff obtained appropriate documentation for advance directives before allowing others to sign health care decisions for residents. This affected 3 of 20 sampled residents.
F658 Comprehensive Care Plans: The facility failed to ensure care and treatment met professional standards, including proper medication administration and following physician orders. This affected six residents.
F677 ADL Care: The facility failed to ensure dependent residents received necessary services to maintain nutrition, grooming, and hygiene. This affected four of 20 sampled residents.
F684 Quality of Care: The facility failed to notify a resident's physician timely after staff completed a straight catheter procedure and noted abnormal findings. This affected one resident.
F689 Free of Accident Hazards: The facility failed to monitor residents to prevent smoking hazards and failed to monitor safe water temperatures. This affected the entire facility census.
F695 Respiratory Care: The facility failed to ensure proper respiratory care including oxygen tubing and concentrator maintenance. This affected three residents.
F759 Medication Errors: The facility failed to ensure medication error rates were below 5%, with a 13.79% error rate observed. This affected two residents.
F804 Food and Drink: The facility failed to serve food at safe and palatable temperatures and failed to monitor food temperatures adequately. This affected the facility census.
F880 Infection Control: The facility failed to maintain an infection prevention and control program, including hand hygiene and glove use during resident care. This affected two residents.
Report Facts
Facility census: 93
Sampled residents affected: 2
Sampled residents affected: 3
Sampled residents affected: 6
Sampled residents affected: 4
Sampled residents affected: 1
Sampled residents affected: 3
Sampled residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Johnson | LNHA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Nurses | DON | Interviewed regarding staff training and resident care practices |
| Dietary Manager | DM | Interviewed regarding dietary service and resident complaints |
| Social Service Director | SSD | Interviewed regarding advance directives and resident care |
| Licensed Practical Nurse | LPN | Observed administering medications and interviewed about care practices |
Inspection Report
Life Safety
Census: 93
Capacity: 120
Deficiencies: 2
Date: Dec 13, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility failed to meet several Life Safety Code requirements related to egress doors and fire alarm system testing and maintenance. Deficiencies included improper delayed-egress locking arrangements and failure to ensure semi-annual inspection of the automatic fire alarm system.
Deficiencies (2)
K222 Egress Doors: The facility failed to maintain two of three sets of delayed-egress designated emergency exit doors on the Special Care Unit to release and open upon fire alarm activation. This affected 18 residents and did not meet locking arrangement requirements.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to ensure semi-annual inspection of the automatic fire alarm system, risking all residents in the event of a fire emergency.
Report Facts
Facility capacity: 120
Census: 93
Residents affected: 18
Inspection Report
Routine
Census: 93
Deficiencies: 11
Date: Dec 13, 2019
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident rights, care, medication administration, infection control, respiratory care, and safety.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during meals, improper advance directive documentation, medication administration errors, inadequate respiratory care, failure to monitor smoking safety, unsafe water temperatures, food served at unsafe temperatures, and lapses in infection prevention practices.
Deficiencies (11)
Staff failed to assist residents with meals in a dignified manner, including standing while feeding and not sitting at eye level.
Facility failed to ensure appropriate verification of incapacity before allowing durable power of attorney to sign advance directives.
Staff failed to follow manufacturer guidelines and facility policy when administering insulin, eye drops, nasal sprays, and inhalers.
Staff failed to provide complete perineal care and did not change gloves or wash hands appropriately during incontinent care.
Facility failed to notify physician timely after straight catheterization without order and noted tea colored urine, resulting in resident hospitalization for UTI and sepsis.
Resident found with lighter in room contrary to facility smoking policy; water temperatures in resident-accessible faucets exceeded safe limits.
Staff failed to ensure oxygen therapy was administered according to physician orders, including failure to clean filters and monitor oxygen tank levels.
Medication administration errors occurred including failure to prime insulin pens before administration.
Staff failed to follow proper nasal spray administration technique including failure to have resident blow nose and occlude opposite nostril.
Food served to residents was sometimes cold and not at safe temperatures.
Staff failed to follow infection prevention practices including hand hygiene and glove changes during incontinent care and medication administration.
Report Facts
Facility census: 93
Medication error rate: 13.79
Insulin dose: 12
Insulin dose: 10
Insulin dose: 14
Oxygen liters: 2
Oxygen liters: 3
Oxygen liters: 2
Hot water temperature: 129.2
Hot water temperature: 126.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in undignified feeding and meal assistance observations |
| Director of Nursing | Director of Nursing | Provided interviews on multiple deficiencies including feeding, advance directives, medication administration, respiratory care, and infection control |
| Dietary Manager | Dietary Manager | Interviewed regarding food service and resident complaints about food temperature and quality |
| LPN A | Licensed Practical Nurse | Observed administering insulin and oxygen therapy; interviewed about medication administration and oxygen use |
| CMT B | Certified Medication Technician | Observed administering eye drops and nasal spray |
| CNA I | Certified Nurse Aide | Observed providing perineal care without changing gloves or washing hands |
Inspection Report
Plan of Correction
Census: 97
Deficiencies: 10
Date: Jan 10, 2019
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding care and services provided to residents at LaVerna Senior Living, including perineal care, restorative nursing, medication administration, infection control, and other nursing home requirements.
Findings
The facility was found deficient in multiple areas including failure to provide proper perineal care, restorative nursing services, medication storage and administration, infection control, and safety measures such as gait belt transfers and smoking assessments. The facility census was 97 at the time of inspection.
Deficiencies (10)
F677: The facility failed to assure staff provided complete perineal care to four dependent, incontinent residents, including proper cleansing and hygiene techniques.
F688: The facility failed to provide restorative nursing services to maintain range of motion and mobility for three sampled residents and lacked a policy for restorative services.
F689: The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for one resident requiring a gait belt.
F690: The facility failed to provide appropriate care to prevent urinary tract infections and maintain continence for residents with indwelling catheters and incontinence.
F693: The facility failed to provide appropriate care and monitoring for residents receiving enteral nutrition via feeding tubes, including checking gastric residual volumes.
F755: The facility failed to correctly document the administration of controlled medications and maintain accurate medication records.
F759: The facility failed to ensure medication error rates were less than 5%, with staff administering medications with errors affecting three of 20 sampled residents.
F761: The facility failed to ensure proper labeling, storage, and disposal of drugs and biologicals, including controlled substances and multi-dose bottles.
F812: The facility failed to prepare food in a clean and sanitary environment, including dirty ice machines and unclean kitchen areas.
F880: The facility failed to establish and maintain an infection prevention and control program, including hand hygiene, glove use, and perineal care protocols.
Report Facts
Facility census: 97
Sampled residents: 20
Medication error rate: 11.5
Medication error opportunities: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nurse Aide | Named in findings related to improper perineal care |
| CNA A | Certified Nurse Aide | Named in findings related to improper perineal care and gait belt use |
| CNA E | Certified Nurse Aide | Named in findings related to perineal care and catheter care |
| LPN B | Licensed Practical Nurse | Named in medication administration and controlled substance findings |
| LPN C | Licensed Practical Nurse | Named in medication administration and controlled substance findings |
| DON | Director of Nursing | Named in multiple interviews and corrective action plans |
| RA A | Restorative Aide | Named in restorative nursing service findings |
| RA B | Restorative Aide | Named in restorative nursing service findings |
| RA C | Restorative Aide | Named in restorative nursing service findings |
Inspection Report
Life Safety
Census: 96
Capacity: 120
Deficiencies: 13
Date: Jan 10, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related fire safety regulations.
Findings
The facility failed to meet several fire safety requirements including staff access to all areas in case of fire, maintenance of fire-rated construction standards, unobstructed emergency exits, proper door functionality, fire drill compliance, safe use of electrical equipment, and proper storage of oxygen cylinders. Multiple deficiencies were cited with potential risk to residents and staff.
Deficiencies (13)
K100: The facility failed to ensure staff had access to all areas, including locked offices, in case of a fire emergency.
K161: The facility failed to maintain the one-hour fire-rated construction standard of smoke compartments, with gaps and holes in ceiling tiles and unsealed penetrations.
K211: The facility failed to maintain emergency exits free from hanging items or signs that obstruct the exits, including unauthorized STOP signs.
K363: The facility failed to provide corridor doors that had no impediment to closing and ensured doors contained no holes.
K712: The facility failed to conduct fire drills as required by NFPA 101, missing drills on multiple shifts and months.
K920: The facility failed to assure the safe use of power strips, with medical equipment connected unsafely and extension cords used improperly.
K923: The facility failed to store oxygen cylinders properly, with unsecured tanks and lack of signage designating full and empty tanks.
A2010: Oxygen storage did not comply with NFPA 99 requirements for racks or fasteners to prevent damage or dislocation of cylinders.
A2049: The facility failed to maintain all exit and directional signs clearly legible and electrically illuminated at all times.
A2058: The facility failed to maintain fire drills and emergency preparedness plans as required by NFPA standards.
A2065: The facility failed to meet fire safety training requirements including prevention, detection, evacuation, and alarm response.
A3001: The building was not substantially constructed or maintained in good repair, violating construction standards for licensed facilities.
A3037: Extension cords and duplex receptacles were not used or installed according to Underwriters Laboratories standards.
Report Facts
Facility capacity: 120
Resident census: 96
Smoke compartments affected: 11
Residents affected by corridor door deficiency: 39
Residents affected by emergency exit obstruction: 42
Residents affected by power strip deficiency: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Darren Johnson | Administrator | Signed the plan of correction and involved in interviews regarding fire safety deficiencies |
| Maintenance Supervisor | Interviewed regarding locked offices, ceiling tile issues, door repairs, and fire drill failures |
Inspection Report
Plan of Correction
Census: 99
Deficiencies: 2
Date: Jun 20, 2018
Visit Reason
The visit was conducted to investigate deficiencies related to the facility's failure to meet professional standards of care, specifically regarding the removal of staples from a surgical site on a resident.
Findings
The facility failed to obtain physician orders for the removal of staples from a surgical site for one sampled resident. Documentation and nursing notes showed the staples remained in place without physician orders for removal, and the Director of Nursing confirmed no such orders existed.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). The facility failed to follow acceptable standards of practice by not obtaining physician orders to remove staples from a surgical site for one resident.
A4074 19 CSR 30-85.042(67) Nursing Care per Resident Condition. The facility did not provide personal attention and nursing care consistent with current acceptable nursing practice as evidenced by the failure to address the staple removal issue.
Report Facts
Resident census: 99
Staples on surgical site: 20
Staple removal order completion date: Jul 20, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Johnson | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Interviewed on 6/20/18 regarding lack of physician orders for staple removal |
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