Deficiencies (last 4 years)
Deficiencies (over 4 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
214% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 3
Dec 30, 2025
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with state and federal regulations regarding medication storage and safety in the facility.
Findings
The facility failed to ensure all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to keys. Specifically, a crash cart was found unlocked and a tube of topical analgesic cream was found in a resident's room without an order, posing potential risks of accidental overdose or misuse.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to store all drugs and biologicals in locked compartments and restrict access to authorized personnel. | Level of Harm - Minimal harm or potential for actual harm |
| Crash cart was found unlocked and accessible to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Topical analgesic cream found in Resident #1's room without a physician's order. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for medication storage: 10
Crash carts reviewed: 3
BIMS score: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Interviewed regarding crash cart locking and medication safety |
| LVN C | Licensed Vocational Nurse | Interviewed regarding medication storage and resident safety |
| ADON A | Assistant Director of Nursing | Interviewed regarding crash cart locking procedures and staff education |
| Administrator | Interviewed regarding facility expectations for medication storage and safety |
Inspection Report
Deficiencies: 3
Sep 30, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing safe and appropriate respiratory care to residents who require it.
Findings
The facility failed to ensure that respiratory care equipment for Resident #1 was properly stored in bags when not in use, which could place the resident at risk for respiratory infection and inadequate respiratory care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1's sleep apnea mask was properly stored in a bag when not in use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #1's nebulizer mask was properly stored in a bag when not in use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #1's nasal canula attached to the oxygen tank on his wheelchair was properly stored in a bag when not in use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Oxygen flow rate: 4
Nebulizer solution dosage: 3
BIMS score: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding improper storage of respiratory equipment | |
| RN G | Interviewed regarding improper storage of respiratory equipment |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 20, 2025
Visit Reason
The inspection was conducted in response to a complaint regarding the facility's failure to maintain the privacy and confidentiality of residents' personal medical records.
Findings
The facility failed to ensure the privacy of Resident #94's medical records, which were mistakenly handed to Resident #93's representative during discharge. This breach could expose residents to psychological or financial harm. The facility also reviewed policies related to protected health information and HIPAA compliance.
Complaint Details
The complaint investigation revealed that Resident #94's face sheet containing personal information was mistakenly given to Resident #93's representative during discharge. The incident likely occurred two years prior, with no similar incidents reported in the past 12 months.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure residents' personal and medical records were kept private and confidential, resulting in unauthorized disclosure of Resident #94's information. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the privacy breach incident and facility policies on protecting resident information. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 20, 2025
Visit Reason
The inspection was conducted in response to a complaint regarding privacy of medical records and medication error rates, as well as food safety concerns in the facility's kitchen.
Findings
The facility failed to protect residents' personal medical information by mistakenly handing Resident #94's private records to Resident #93's representative. Additionally, the medication error rate was 13.33%, exceeding the 5% threshold, due to late administration of medications to three residents. The facility also failed to properly date and discard opened food items in the kitchen, risking foodborne illness.
Complaint Details
The complaint involved privacy violations where Resident #94's face sheet was mistakenly given to Resident #93's representative, and concerns about medication errors and food safety practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure residents' personal and medical records were kept private and confidential, resulting in Resident #94's information being disclosed to Resident #93's representative. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate was 13.33%, exceeding the 5% limit, due to late administration of medications to Residents #28, #74, and #89. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store food in accordance with professional standards by not discarding food items past their expiration or discard dates in the kitchen refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 13.33
Medication errors: 4
Medication administration window: 7
Medication administration window: 10
Medication administration window: 2
Medication administration window: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MA A | Medication Aide | Administered medications late to Residents #28, #74, and #89; interviewed about medication administration practices. |
| ADON B | Assistant Director of Nursing | Provided information about medication administration windows and risks of late medication. |
| Clinical Resource Nurse C | Clinical Resource Nurse | Responsible for checking MARs weekly and discussed risks of medication errors. |
| DON | Director of Nursing | Interviewed regarding privacy breach incident and medication administration policies. |
| MD | Medical Doctor | Interviewed about risks related to late medication administration. |
| Dietary Manager | Interviewed about food storage practices and importance of discard dates. |
Inspection Report
Routine
Deficiencies: 9
Jan 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, reasonable accommodation, environment, grievance procedures, care planning, activities of daily living, pharmaceutical services, infection control, and gastrostomy tube management at Legend Oaks Healthcare and Rehabilitation Garland.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for medication, failure to ensure call lights were accessible, inadequate housekeeping and maintenance, failure to inform residents about grievance procedures, incomplete care plans, inconsistent provision of showers, delayed medication reordering, lack of clear orders for feeding tube downtime, and lapses in infection control practices such as hand hygiene.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to obtain signed informed consent for administration of Lamictal for Resident #28. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure call light systems were accessible to residents #68 and #236. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a safe, clean, comfortable, and homelike environment in 11 resident rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to make grievance filing information available to Resident #71. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a comprehensive care plan including fall mat for Resident #44. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide scheduled showers consistently for Residents #1 and #36. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #76 had a physician order for enteral feeding downtime. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely reorder medications for Residents #3, #12, #56, and #58. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to perform proper hand hygiene by staff before applying splint to Resident #43 and during incontinence care for Resident #18. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for reasonable accommodation: 12
Residents affected by call light accessibility deficiency: 2
Resident rooms observed for housekeeping: 27
Resident rooms found unclean: 11
Residents reviewed for grievances: 3
Residents reviewed for care plans: 3
Residents reviewed for ADL care: 3
Residents reviewed for gastrostomy tube management: 1
Residents reviewed for pharmaceutical services: 15
Residents reviewed for infection control: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ADON A | Assistant Director of Nursing | Responsible for reviewing pharmacy recommendations and ensuring consents were obtained for medications |
| DON | Director of Nursing | Oversight of resident care, infection control, and medication management |
| CNA S | Certified Nursing Assistant | Observed call light accessibility issues and acknowledged oversight |
| ADON R | Assistant Director of Nursing | Responsible for call light accessibility and staff in-service |
| Housekeeping A | Housekeeper | Reported challenges cleaning certain resident rooms |
| Housekeeping Supervisor | Housekeeping Supervisor | Responsible for training and oversight of housekeeping staff |
| SW | Social Worker | Responsible for ensuring residents knew how to file grievances |
| Operations Manager | Operations Manager | Met with resident regarding grievance |
| ADON H | Assistant Director of Nursing | Addressed hospice care and shower provision issues |
| CNA C | Certified Nursing Assistant | Observed not performing hand hygiene during incontinence care |
| LVN N | Licensed Vocational Nurse | Observed medication blister packs running low and confirmed feeding tube order issues |
| LVN M | Licensed Vocational Nurse | Clarified feeding tube downtime order with NP |
| CMA B | Certified Medication Aide | Observed preparing medications and responsible for re-ordering medications |
Inspection Report
Routine
Deficiencies: 12
Jan 19, 2024
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, reasonable accommodation, environment safety, grievance procedures, restraint use, care planning, activities of daily living, respiratory care, pharmaceutical services, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for medication, call light accessibility, cleanliness of resident rooms, grievance notification, restraint orders, care plan implementation, ADL assistance, respiratory equipment maintenance, timely medication reordering, food storage and sanitation, and infection prevention practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to obtain signed informed consent for Lamictal medication for Resident #28. | Level of Harm - Minimal harm or potential for actual harm |
| Call light system not accessible to residents #68 and #236. | Level of Harm - Minimal harm or potential for actual harm |
| Resident rooms (including #1, 14, 15, 23, 36, 48, 51, 52, 56, 70, 80) not cleaned, sanitized, and maintained properly. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #71 was not informed on how to file a grievance. | Level of Harm - Minimal harm or potential for actual harm |
| Residents #14, #49, and #63 had physical restraints (scoop mattress or positioning wedge) without physician orders or assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #44 did not have a fall mat in place as required by care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Residents #1 and #36 did not consistently receive scheduled showers. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #76 had no physician order for enteral feeding downtime initially, risking underfeeding or overfeeding. | Level of Harm - Minimal harm or potential for actual harm |
| Residents #14, #15, #55, and #67 had respiratory care deficiencies including unclean or undated nebulizer tubing, improperly stored nebulizer mask, and humidifier without water. | Level of Harm - Minimal harm or potential for actual harm |
| Residents #3, #12, #56, and #58 had medications not reordered in a timely manner risking medication shortages. | Level of Harm - Minimal harm or potential for actual harm |
| Food in the kitchen was not properly labeled, dated, sealed, and the ice machine was not thoroughly cleaned. | Level of Harm - Minimal harm or potential for actual harm |
| ADON R failed to perform hand hygiene before applying a resting hand splint to Resident #43. CNA C failed to perform hand hygiene during incontinence care for Resident #18. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for grievances: 3
Residents reviewed for respiratory care: 6
Residents reviewed for pharmaceutical services: 15
Residents reviewed for infection control: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ADON R | Assistant Director of Nursing | Responsible for reviewing pharmacy recommendations, respiratory care, medication reordering, infection control, and call light accessibility |
| CMA B | Certified Medication Aide | Responsible for medication preparation and reordering; failed to reorder medications timely |
| LVN N | Licensed Vocational Nurse | Involved in medication preparation and respiratory care; failed to reorder medications timely and clarify feeding tube downtime |
| DON | Director of Nursing | Oversaw multiple areas including infection control, medication management, respiratory care, and care planning |
| CNA C | Certified Nursing Assistant | Failed to perform hand hygiene during incontinence care |
| RN P | Registered Nurse | Provided care to Resident #55 and noted improper nebulizer mask storage |
| Housekeeping Supervisor | Responsible for housekeeping and maintenance; acknowledged ice machine cleaning responsibility | |
| Dietary Manager | Managed kitchen and food safety; addressed food labeling and storage issues | |
| Dietician | Managed kitchen and food safety; addressed food labeling and storage issues |
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 14, 2023
Visit Reason
The inspection was conducted following a complaint regarding medication administration errors and the use of chemical restraints at the facility.
Findings
The facility failed to prevent the use of unnecessary psychotropic medications and chemical restraints, specifically administering a discontinued medication (Xanax) to Resident #1. Additionally, the facility failed to ensure proper medication administration for Resident #2 and failed to maintain sharps containers properly, posing risks to residents.
Complaint Details
The complaint involved administration of a discontinued medication (Xanax) to Resident #1 by LVN A, who admitted to giving the medication twice despite no current order. The family member reported the incident, and the DON investigated, confirming the medication was given without orders and that the medication vial was not removed after discontinuation. LVN A was terminated immediately.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to prevent use of unnecessary psychotropic medications or chemical restraints, including administering discontinued Xanax to Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure sharps containers were changed before becoming overfilled, creating hazard risks. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide pharmaceutical services ensuring accurate medication administration, including failure to observe Resident #2 taking medications and administering discontinued Xanax to Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from significant medication errors; Resident #1 was administered discontinued Xanax. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for chemical restraints: 4
Sharps containers overfilled: 8
Medications found at Resident #2 bedside: 4
Doses of Xanax unaccounted for: 8.5
Date of survey completion: Oct 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Administered discontinued Xanax to Resident #1 twice; terminated immediately after investigation. |
| DON | Director of Nursing | Conducted investigation into medication errors and oversaw corrective actions. |
| LVN C | Licensed Vocational Nurse | Documented medication administration for Resident #2 but failed to ensure medications were actually taken. |
| RN E | Registered Nurse | Observed medications at Resident #2 bedside and confirmed they appeared not to have been taken. |
| RN F | Registered Nurse | Observed LVN A administer liquid Xanax to Resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 19, 2023
Visit Reason
The inspection was conducted to investigate complaints related to medication storage security and infection prevention and control practices, including COVID-19 cohorting and PPE use.
Findings
The facility failed to secure medication carts by leaving them unlocked, risking drug diversion. Additionally, the facility did not maintain proper infection control by failing to ensure staff properly donned and doffed PPE and by not cohorting COVID-19 positive and negative residents appropriately, placing residents at risk of infection.
Complaint Details
The complaint investigation revealed failures in medication cart security and infection control practices, including improper PPE use by staff and failure to separate COVID-19 positive and negative residents, leading to potential cross-contamination and infection risk.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to store all drugs and biologicals in locked compartments for two medication carts, leaving medications accessible. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to establish and maintain an infection prevention and control program, including improper PPE use and failure to cohort COVID-19 positive and negative residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication carts unsecured: 2
Residents reviewed for infection control: 9
Staff reviewed for infection control: 3
COVID-19 positive residents identified on 07/19/23: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in medication cart security deficiency for leaving Cart 2 unlocked |
| CMA A | Certified Medication Aide | Named in medication cart security deficiency for not locking Cart 1 |
| ADON | Assistant Director of Nursing | Provided expectations and training details related to medication cart security and infection control |
| Housekeeper A | Failed to properly don PPE before entering COVID hot hall | |
| Floor Tech A | Exited COVID hot hall without removing PPE and moved mattress improperly | |
| Housekeeping Supervisor | Provided education and supervision related to PPE use and infection control | |
| LVN B | Licensed Vocational Nurse | Responsible for relocating COVID positive resident and described cohorting procedures |
| Administrator | Provided statements on staff training and infection control policies | |
| Clinical Resources | Assisted infection control specialist and provided training on PPE and infection control |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
May 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision and accident prevention for Resident #1, who fell in the shower room and sustained a fracture.
Findings
The facility failed to ensure adequate supervision for Resident #1, who was left unattended in the shower room, resulting in a fall and fracture of the distal femur. The facility identified deficiencies in staff training, supervision, and documentation of residents' ADL needs. Immediate Jeopardy was identified but later removed after the facility implemented corrective actions including staff training, installation of grip tape, and monitoring procedures.
Complaint Details
The complaint investigation revealed that CNA C left Resident #1 unattended in the shower room despite the resident requiring one-person assistance with bathing. Resident #1 fell and sustained a fracture of the distal femur. The facility reported the incident to HHSC and implemented a Plan of Removal including staff training and monitoring. Immediate Jeopardy was identified on 05/12/23 and removed on 05/14/23, with the facility remaining out of compliance at a severity level of actual harm.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to Resident #1 in the shower room, resulting in a fall and fracture. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents present: 71
Date of Immediate Jeopardy identification: May 12, 2023
Date of Immediate Jeopardy removal: May 14, 2023
Number of residents reviewed: 7
Knowledge checks frequency: 10
Visual checks frequency: 5
Duration of monitoring: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Named in supervision failure leading to Resident #1's fall |
| LVN A | Licensed Vocational Nurse | Assessed Resident #1 after fall |
| RN B | Registered Nurse | Documented Resident #1's injury and ordered hospital transfer |
| DON | Director of Nursing | Provided coaching to CNA C and oversaw Plan of Removal implementation |
| Administrator | Facility Administrator | Oversaw facility response and Plan of Removal |
| Director of Rehab | Rehabilitation Director | Responsible for updating special instructions and ADL care instructions |
| RN J | Registered Nurse | Provided education and in-servicing for Plan of Removal |
| RN L | Registered Nurse | Provided in-servicing for Plan of Removal |
| RN M | Registered Nurse | Company educator responsible for staff training |
| RN N | Registered Nurse | Educated clinical and non-clinical staff on abuse, neglect, and ADL care |
| RN P | Registered Nurse | Participant in Plan of Removal education and monitoring |
| RN O | Registered Nurse | Participant in Plan of Removal education and monitoring |
| CNA F | Certified Nursing Assistant | Completed in-service training and competency tests |
| CNA G | Certified Nursing Assistant | Completed in-service training and competency tests |
| CNA H | Certified Nursing Assistant | Completed in-service training and competency tests |
| LVN I | Licensed Vocational Nurse | Completed in-service training and competency tests |
| RN K | Registered Nurse | Completed in-service training and competency tests |
Inspection Report
Routine
Deficiencies: 2
Mar 31, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with food service safety standards, specifically focusing on food storage, preparation, distribution, and serving practices in the kitchen.
Findings
The facility failed to maintain adequate temperature logs for the refrigerator and freezer and failed to dispose of expired or spoiled foods, including spoiled lettuce and outdated tortillas and hamburger buns. These deficiencies posed a minimal harm risk to residents due to potential foodborne illness.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to keep adequate records of temperatures for the refrigerator and freezer | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure disposal of expired or spoiled foods including spoiled lettuce and expired tortillas and hamburger buns | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Packages of corn tortillas: 6
Packages of hamburger buns: 3
Heads of spoiled lettuce: 3
Inspection Report
Deficiencies: 4
Nov 9, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents received proper hearing evaluations, improper use of feeding tube de-cloggers, inadequate labeling and storage of insulin medications, and failure to maintain proper hand hygiene during incontinent care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure residents received proper treatment and assistive devices to maintain vision and hearing abilities, specifically failure to evaluate Resident #9 for hearing aids by an audiologist. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure appropriate care for a resident with a feeding tube, including use of unauthorized feeding tube clog remover devices by LVN C on Resident #23. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure drugs and biologicals were labeled in accordance with professional principles and stored properly, including undated and expired insulin pens and vials on nurse medication carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an infection prevention and control program, including failure of CNAs to perform hand hygiene between glove changes during incontinent care for Resident #8. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medications administered: 8
Feeding tube clog remover boxes ordered: 2
Feeding tube clog remover quantity per box: 10
Insulin pens undated: 5
Insulin vials expired or undated: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Used feeding tube clog remover on Resident #23's G-tube against facility policy |
| RN E | Registered Nurse | Interviewed regarding feeding tube clogging procedures and insulin medication management |
| RN D | Registered Nurse | Interviewed regarding feeding tube declogging and insulin pen management |
| CNA A | Certified Nursing Assistant | Observed failing to perform hand hygiene between glove changes during incontinent care for Resident #8 |
| CNA B | Certified Nursing Assistant | Observed failing to perform hand hygiene between glove changes during incontinent care for Resident #8 |
| Social Worker | Interviewed regarding audiology screening and Resident #9's hearing evaluation | |
| Interim DON | Director of Nursing | Interviewed regarding feeding tube declogging policy and insulin medication audits |
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