Inspection Reports for
Lincoln County Nursing &Amp; Rehab
1145 EAST CHERRY STREET, TROY, MO, 63379-1520
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
15.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
180% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
80 residents
Based on a November 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Date: Nov 17, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate care and services to a resident diagnosed with vascular dementia, including failure to identify triggers for aggression and combativeness and lack of dementia care training for staff.
Complaint Details
The investigation was complaint-driven based on concerns from the resident's spouse/POA about bruising and aggressive behaviors by the resident during care. The complaint included allegations of staff not responding appropriately to the resident's aggression and lack of dementia care training for staff. The complaint was substantiated with findings of inadequate care and training.
Findings
The facility failed to provide appropriate dementia care for Resident #1, who exhibited aggression and combativeness during care. Staff continued care despite the resident's behaviors, and the facility failed to provide dementia care training to staff or update the resident's care plan with individualized interventions. Several staff members reported lack of dementia training and inadequate knowledge of the resident's behaviors.
Deficiencies (1)
Failure to provide appropriate treatment and services to a resident with dementia, including failure to identify triggers for aggression and combativeness and failure to provide dementia care training to staff.
Report Facts
Facility census: 80
Medications: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Named in relation to resident aggression incident and sent home after bruising incident |
| LPN F | Licensed Practical Nurse | Assisted with resident transfer during combative episode |
| LPN A | Licensed Practical Nurse | Assisted with resident transfer and reported lack of dementia training |
| NA J | Nurse Assistant | Reported resident behaviors and lack of dementia training |
| CNA I | Certified Nursing Assistant | Reported resident injury and combative behaviors |
| CNA K | Certified Nursing Assistant | Reported resident behaviors and care observations |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for staff notification and dementia care training |
| Administrator | Administrator | Interviewed regarding staff training and knowledge of resident behaviors |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Interviewed regarding resident's psychiatric status and staff training expectations |
Inspection Report
Routine
Census: 71
Deficiencies: 2
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with care standards, including provision of activities of daily living assistance, staffing adequacy, and hygiene care for residents.
Findings
The facility failed to provide adequate care and assistance with positioning, nail care, and bathing for several residents. Staffing levels were insufficient to meet residents' needs, resulting in missed showers and inadequate hygiene care. The facility did not have a staffing policy and consistently had fewer CNA hours than required by their own facility assessment.
Deficiencies (2)
Failure to provide necessary care and services to maintain comfortable positioning in bed for one resident, nail care for one resident, and bathing for three residents who required assistance.
Failure to provide sufficient staffing to meet residents' needs, including bathing for three residents.
Report Facts
Facility census: 71
Average daily census: 60
Certified Nurse Aide (CNA) hours required: 112
Certified Nurse Aide (CNA) hours provided: 84
Certified Nurse Aide (CNA) hours provided: 101
Certified Nurse Aide (CNA) hours provided: 104
Certified Nurse Aide (CNA) hours provided: 98
Certified Nurse Aide (CNA) hours provided: 80
Certified Nurse Aide (CNA) hours provided: 104
Certified Nurse Aide (CNA) hours provided: 80
Certified Nurse Aide (CNA) hours provided: 96
Certified Nurse Aide (CNA) hours provided: 68
Certified Nurse Aide (CNA) hours provided: 105
Certified Nurse Aide (CNA) hours provided: 93.5
Certified Nurse Aide (CNA) hours provided: 88
Certified Nurse Aide (CNA) hours provided: 96
Certified Nurse Aide (CNA) hours provided: 82
Certified Nurse Aide (CNA) hours provided: 98
Certified Nurse Aide (CNA) hours provided: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Interviewed about resident care and shower refusals |
| CNA D | Certified Nurse Aide | Interviewed about resident care and shower refusals |
| LPN A | Licensed Practical Nurse | Interviewed about resident care and shower assistance |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about shower sheets and staffing |
| Director of Nursing | Director of Nursing | Interviewed about staffing and scheduling |
| Administrator | Administrator | Interviewed about staffing and nursing schedule |
| Resident #6 | Resident interviewed about roommate's bathing |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 2
Date: Oct 8, 2024
Visit Reason
The inspection was conducted due to concerns about medication tampering, missing narcotics, and improper medication storage and documentation, as well as complaints about food temperature and quality.
Complaint Details
The investigation was complaint-related, focusing on medication tampering, missing narcotics, and food temperature issues. Substantiation status is not explicitly stated.
Findings
The facility failed to maintain a safe and effective medication system, including tampering with morphine and insulin pens, missing oxycodone from the emergency medication kit, and incomplete narcotic counts. Additionally, the facility failed to provide food items at safe and appetizing temperatures, with cold food and beverages served to residents.
Deficiencies (2)
Failure to maintain a safe and effective medication system with tampered morphine and insulin pens, missing oxycodone, and incomplete narcotic counts.
Failure to provide food items at safe and appetizing temperatures, including cold meals and beverages not kept on ice.
Report Facts
Facility census: 71
Morphine dosage: 0.25
Food temperature: 118
Food temperature: 62
Food temperature: 60
Food temperature: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Reported morphine medication tampering and notified Assistant Director of Nursing |
| Director of Nursing | Director of Nursing (DON) | Provided information on medication tampering, narcotic audits, and expectations for medication counts |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Involved in narcotic audits and interviews regarding medication handling |
| CMT B | Certified Medication Technician | Described narcotic counting procedures and shift change practices |
| CMT C | Certified Medication Technician | Described narcotic counting procedures and shift change practices |
| Administrator | Facility Administrator | Provided statements on medication policies, narcotic handling, and food service expectations |
| Dietary Manager | Dietary Manager | Provided information on food temperature policies and meal service observations |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 31
Date: May 23, 2024
Visit Reason
The inspection was conducted as the annual survey to assess compliance with state and federal regulations for nursing home care.
Findings
The facility had multiple deficiencies including failure to provide dignified care, inadequate grievance response, improper notification of resident fund balances, failure to provide required Medicare notices, poor environmental maintenance, insufficient resident council communication, failure to notify residents of transfers and bed hold policies, incomplete assessments and care plans, medication administration errors, inadequate staffing and training, inconsistent code status documentation, deficient infection control practices, and lack of a functional quality assurance program.
Deficiencies (31)
Failure to provide care in a manner that enhanced resident dignity for multiple residents.
Failure to consistently address and respond to concerns brought forth by the resident council.
Failure to notify resident and/or representative when resident's trust account reached Medicaid resource limit.
Failure to provide appropriate Medicare Skilled Nursing Facility Advance Beneficiary Notice (SNF-ABN) when skilled services ended and resident remained in facility.
Failure to maintain a safe, clean, comfortable and homelike environment including poor housekeeping, soiled resident rooms, missing linens, and facility disrepair.
Failure to ensure resident council grievances were accepted and addressed without retaliation or reprisal.
Failure to notify resident or representative of certain balances and convey resident funds upon discharge, eviction, or death.
Failure to complete a thorough investigation of an allegation of abuse including incomplete staff and resident interviews.
Failure to provide timely notification to resident and/or representative before transfer or discharge including appeal rights.
Failure to notify resident or representative in writing of bed hold policy at time of transfer to hospital or therapeutic leave.
Failure to develop and implement a comprehensive person-centered care plan specific to resident needs.
Failure to update care plan interventions after significant changes in resident condition including cognition, mobility, medication changes, and falls.
Failure to ensure medications were available and administered as ordered including insulin pen priming errors and missing medications.
Failure to secure medications properly when unattended and out of sight with residents nearby.
Dietary manager lacked required certification and training for position.
Failure to ensure food served was palatable, attractive, and at safe and appetizing temperature.
Failure to store, prepare, and serve food under sanitary conditions including unclean equipment, improper glove use, and food storage violations.
Failure to provide sufficient nursing staff including lack of RN coverage for required hours and reliance on agency staff.
Failure to ensure nurse aides completed required training and competencies including CNA certification within four months of hire.
Failure to provide required in-service education hours and competencies for nurse aides.
Failure to post required nurse staffing information including facility name, census, staff titles, and hours worked.
Failure to provide appropriate treatment and services for resident with mental illness including inadequate behavioral interventions and supervision.
Failure to provide appropriate foot care including timely podiatry services and nail care.
Failure to provide restorative nursing services to residents with limited mobility and range of motion.
Failure to provide appropriate care for residents with indwelling urinary catheters and incontinence care to prevent infections.
Failure to follow infection control practices during blood glucose monitoring and oxygen therapy administration.
Failure to ensure staff had completed required tuberculosis testing and follow up.
Failure to ensure residents' drug regimens were reviewed and unnecessary drugs avoided including lack of follow up on pharmacy recommendations and gradual dose reductions.
Failure to ensure insulin pens were primed prior to administration as per manufacturer instructions.
Failure to ensure medications and biologicals were labeled and stored securely.
Failure to employ a qualified dietary manager with required certification and education.
Report Facts
Resident census: 67
Deficiency counts: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nurse Assistant | Named in multiple findings related to hygiene, infection control, and care deficiencies |
| CNA PP | Certified Nurse Assistant | Named in training deficiencies |
| LPN R | Licensed Practical Nurse | Named in medication administration and oxygen therapy findings |
| DON | Director of Nursing | Named in multiple interviews regarding facility deficiencies and oversight |
| Administrator | Interim Administrator | Named in interviews regarding facility management and deficiencies |
| Dietary Manager | Dietary Manager | Named in interviews regarding dietary service deficiencies |
| Activity Director | Activity Director | Named in interviews regarding activity program deficiencies |
| SSD | Social Service Director | Named in interviews regarding grievance and training deficiencies |
| CNA E | Certified Nurse Assistant | Named in infection control and care deficiencies |
| CNA FF | Certified Nurse Assistant | Named in infection control and care deficiencies |
| CMT M | Certified Medication Technician | Named in medication administration findings |
| LPN A | Licensed Practical Nurse | Named in medication administration and infection control findings |
| LPN D | Licensed Practical Nurse | Named in infection control and medication administration findings |
| CNA O | Certified Nurse Assistant | Named in wheelchair safety findings |
| Maintenance Director | Maintenance Director | Named in environmental maintenance findings |
| CNA W | Certified Nurse Assistant | Named in hygiene and infection control findings |
| CNA G | Certified Nurse Assistant | Named in infection control and behavioral findings |
| LPN N | Licensed Practical Nurse | Named in medication administration and infection control findings |
| CNA DD | Certified Nurse Assistant | Named in training and tuberculosis testing findings |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 6
Date: Mar 29, 2024
Visit Reason
The inspection was conducted due to complaints involving verbal abuse of a resident by a Certified Medication Technician and allegations of narcotic medication misappropriation, as well as concerns about resident care including pressure ulcers and staffing adequacy.
Complaint Details
The complaint investigation substantiated verbal abuse of Resident #1 by Certified Medication Technician B, narcotic medication discrepancies involving 21 doses of Schedule II narcotics, failure to provide appropriate care for Resident #3 leading to hospitalization, and inadequate pressure ulcer prevention and treatment for Resident #10. Staffing shortages were also noted as contributing factors.
Findings
The facility failed to protect a resident from verbal abuse by a staff member, failed to thoroughly investigate narcotic medication discrepancies, failed to provide appropriate care and treatment for residents with pressure ulcers and skin breakdown, and failed to maintain adequate staffing levels to meet resident needs. Additionally, narcotic medication records were not properly reconciled and documented.
Deficiencies (6)
Certified Medication Technician verbally abused Resident #1 by yelling, cussing, and threatening the resident, causing actual harm.
Facility failed to investigate narcotic medication discrepancies involving 21 doses of Schedule II narcotics and failed to reconcile narcotic counts weekly.
Resident #3 did not receive appropriate care for ongoing diarrhea, vomiting, and weakness leading to hospitalization for hypokalemia; staff failed to provide ordered potassium supplements, incontinence care, and safe transfers.
Resident #10 developed multiple pressure ulcers due to inadequate prevention and treatment; staff failed to provide appropriate wound care, incontinence care, and repositioning.
Facility failed to provide sufficient nursing staff to meet resident needs, resulting in inadequate care and delayed assistance.
Narcotic medication records were not properly maintained; discrepancies in narcotic counts were not reconciled, and destruction of wasted or dropped narcotics was not verified by two staff.
Report Facts
Facility census: 70
Narcotic discrepancy count: 21
Pressure ulcer measurements: 10
Braden Scale score: 14
Staffing count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT B | Certified Medication Technician | Named in verbal abuse finding and narcotic medication discrepancies |
| CNA F | Certified Nurse Assistant | Named in failure to provide incontinence care and safe transfers for Resident #3 |
| LPN E | Licensed Practical Nurse | Provided statements regarding abuse incident and resident care |
| DON | Director of Nursing | Provided statements regarding narcotic reconciliation and staffing |
| Administrator | Provided statements regarding abuse, narcotic discrepancies, and staffing | |
| Pharmacy Consultant | Conducted narcotic audits and reported discrepancies | |
| ADON | Assistant Director of Nursing | Provided statements regarding narcotic reconciliation and staffing |
Inspection Report
Routine
Census: 69
Deficiencies: 3
Date: Jan 3, 2024
Visit Reason
The inspection was conducted to assess compliance with staffing requirements, resident care including bathing, incontinence care, and RN coverage based on facility assessment and federal guidelines.
Findings
The facility failed to provide sufficient nursing staff to meet resident needs, including inadequate bathing, delayed response to call lights, and insufficient incontinence care for some residents. The facility also failed to maintain required RN coverage for eight hours daily on multiple days reviewed.
Deficiencies (3)
Failed to provide sufficient nursing staff to meet the needs of residents, including failure to provide regular baths/showers and timely response to call lights.
Failed to provide incontinence care for one resident.
Failed to maintain RN staffing for eight consecutive hours a day, seven days a week.
Report Facts
Facility census: 69
Average daily census: 60
CNA staffing hours: 96
CNA staffing hours: 104
RN staffing hours: 0
RN staffing hours: 0
RN staffing hours: 0
RN staffing hours: 0
RN staffing hours: 0
Days without RN coverage: 5
Days without adequate CNA coverage: 10
Residents reviewed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA H | Certified Nursing Assistant | Responsible for Resident #8's care; acknowledged staffing shortages and delayed resident checks |
| NA E | Nursing Assistant | Reported insufficient staffing to meet resident needs |
| NA I | Nursing Assistant | Reported residents checked as often as possible; noted showers might not be completed if staff call in |
| LPN F | Licensed Practical Nurse | Reported staffing shortages and inconsistent bathing and water passing |
| Interim Director of Nursing | Director of Nursing | Reported staffing expectations and acknowledged some difficulties in meeting them |
| Administrator | Facility Administrator | Acknowledged lack of specific staffing policy and staffing shortages; aware of RN coverage requirements |
Inspection Report
Abbreviated Survey
Census: 70
Deficiencies: 3
Date: Oct 17, 2023
Visit Reason
The abbreviated survey was conducted to investigate deficiencies related to pressure ulcer care, rehabilitation services, and infection prevention and control at Lincoln County Nursing & Rehab.
Findings
The facility failed to provide appropriate pressure ulcer care resulting in immediate jeopardy to resident health, delayed rehabilitation services for two residents due to payer source verification issues, and failed to designate a qualified infection preventionist with specialized training. The facility implemented corrective actions to remove the immediate jeopardy related to pressure ulcer care at the time of the survey.
Deficiencies (3)
Failed to ensure one resident with pressure ulcers received necessary treatment and services, including obtaining physician orders, conducting assessments, completing dressing changes, and timely antibiotic treatment, resulting in infection, hospitalization, hospice care, and death.
Failed to follow physician's orders in a timely manner for rehabilitation services for two residents, resulting in decline in strength and mobility.
Failed to designate a qualified infection preventionist who has completed specialized training in infection prevention and control.
Report Facts
Facility census: 70
Pressure ulcer wound measurements: 8.6
Pressure ulcer wound measurements: 4
Pressure ulcer wound measurements: 0.3
Pressure ulcer wound measurements: 4.8
Pressure ulcer wound measurements: 4.8
Pressure ulcer wound measurements: 0.1
Pressure ulcer wound measurements: 0.7
Pressure ulcer wound measurements: 1
Pressure ulcer wound measurements: 0.1
Physical therapy frequency: 3
Occupational therapy frequency: 3
Physical therapy duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in failure to notify physician about wound culture and antibiotic orders |
| LPN B | Licensed Practical Nurse | Noted wounds and documented nursing notes |
| LPN D | Assistant Director of Nursing / Wound Nurse | Notified RN A of culture results and antibiotic orders |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for wound care and therapy services |
| Administrator | Administrator | Interviewed regarding expectations for wound care, therapy services, and infection control |
| Therapy Director | Therapy Director | Interviewed regarding delays in therapy services due to payer source verification |
| Business Office Manager | Business Office Manager | Interviewed regarding payer source verification delays |
| Resident's Physician | Physician / Medical Director | Interviewed regarding expectations for therapy services and wound care |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding infection preventionist role and antibiotic tracking |
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 13
Date: Oct 24, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including resident rights, safety, care planning, infection control, and other health and safety standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, timely and comprehensive assessments, care planning, infection control, staff training, food service quality and timeliness, fall prevention, wound care, and regulatory compliance such as RN coverage and vaccination protocols. Several residents experienced neglect in care such as missed showers, improper catheter care, and inadequate monitoring of pressure ulcers and falls.
Deficiencies (13)
Staff used inappropriate language and failed to promote dignity during resident care and meal service.
Facility failed to complete timely comprehensive and significant change assessments for residents.
Care plans were not developed or updated to reflect resident needs, including for pressure ulcers, catheter care, and fall prevention.
Staff failed to provide scheduled showers and proper perineal care, and failed to perform hand hygiene and glove changes appropriately.
Facility failed to reposition residents at risk for pressure ulcers and failed to complete weekly skin assessments and wound care as ordered.
Facility failed to assess root causes of falls, evaluate interventions, and ensure safe transfers and wheelchair transport.
Facility failed to provide sufficient dietary staff to prepare and serve meals timely, and failed to serve food at proper temperatures and consistency.
Facility failed to ensure sanitary practices in the kitchen including hand hygiene, glove use, and cleanliness of equipment.
Facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program and Quality Assessment and Assurance (QAA) committee.
Facility failed to follow infection control procedures including hand hygiene, glove use, catheter care, and tuberculosis screening.
Facility failed to provide pneumococcal vaccinations according to CDC guidelines for several residents.
Facility failed to provide required RN coverage for at least 8 consecutive hours daily and allowed the DON to serve as charge nurse during high census days.
Facility failed to ensure corridors were equipped with firmly secured handrails on each side of the hall.
Report Facts
Residents affected: 68
Weight loss: 52
Falls: 2
Falls: 1
Falls: 1
Falls: 1
Weight: 181
Weight: 233
Weight: 12.6
Weight: 39.8
Weight: 233.4
Weight: 220.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in wound care and weight monitoring deficiencies |
| CNA U | Certified Nurse Aide | Named in peri care and hygiene deficiencies |
| RN O | Registered Nurse | Named in wound care and infection control deficiencies |
| CNA G | Certified Nurse Aide | Named in hygiene and catheter care deficiencies |
| CNA M | Certified Nurse Aide | Named in hygiene and catheter care deficiencies |
| CNA C | Certified Nurse Aide | Named in hygiene and mechanical lift transfer deficiencies |
| NA G | Nurse Aide | Named in hygiene and catheter care deficiencies |
| CNA N | Certified Nurse Aide | Named in mechanical lift transfer deficiencies |
| CNA I | Certified Nurse Aide | Named in shower and hygiene deficiencies |
| Administrator | Administrator | Named in kitchen staffing and food service deficiencies |
| Dietary Manager | Dietary Manager | Named in food service and kitchen sanitation deficiencies |
| Director of Nurses | Director of Nursing | Named in multiple deficiencies including RN coverage, wound care, infection control, and vaccination |
| Maintenance Supervisor | Maintenance Supervisor | Named in handrail maintenance deficiency |
Inspection Report
Routine
Census: 76
Capacity: 85
Deficiencies: 16
Date: Jun 20, 2019
Visit Reason
Routine inspection of Lincoln County Nursing & Rehab to assess compliance with regulatory requirements including resident rights, care, environment, staffing, medication management, infection control, and food service.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate response to resident council concerns, environmental cleanliness issues, failure to provide scheduled showers for multiple residents, improper medication administration and documentation, insufficient staffing levels, food service deficiencies, infection control lapses, and pest control program inadequacies.
Deficiencies (16)
Staff raised voice and threw an uncapped needle at a resident causing distress.
Facility failed to respond to resident council concerns and failed to document responses.
Facility failed to maintain clean and safe environment including stained tables, flooring, vents, and mold.
Facility failed to provide scheduled showers for 14 residents requiring assistance.
Facility failed to follow professional standards for wound care including undocumented dressing changes and failure to wash hands between wounds.
Facility failed to timely implement measures to prevent development of pressure ulcers and failed to ensure adequate pressure relief and repositioning.
Facility failed to consistently document pain assessments and provide timely pain medication.
Facility failed to have sufficient nursing staff on all shifts to meet resident care needs including assistance with showers.
Facility failed to administer insulin according to manufacturer's recommendations including failure to prime insulin pens.
Facility failed to accurately label insulin vials with open dates.
Facility failed to ensure food was served at proper temperature and prepared according to recipes for special diets.
Facility failed to offer residents a daily bedtime snack and failed to provide snacks in residents' rooms.
Facility failed to ensure kitchen equipment and environment were clean and sanitary, failed to ensure proper food handling including hand hygiene and glove use, failed to properly store eggs, and failed to maintain ice machine and thaw raw chicken properly.
Facility failed to develop and implement a comprehensive infection control program including waterborne pathogen prevention and failed to wash hands during wound care.
Facility failed to follow policies and procedures for pneumococcal vaccinations including education, consent, administration, and documentation.
Facility failed to implement an effective pest control program with ongoing insect and spider infestations and unrepaired structural damage.
Report Facts
Facility census: 76
Total licensed capacity: 85
Residents on mechanical soft diet: 20
Residents on pureed diet: 1
Staffing hours required: 160
Staffing hours provided: 136
Staffing hours provided: 156
Wound measurements: 7.2
Wound measurements: 4.1
Wound measurements: 1.3
Wound measurements: 6.4
Wound measurements: 2.5
Wound measurements: 0.2
Wound measurements: 1.2
Wound measurements: 1.2
Wound measurements: 0.2
Temperature: 116.3
Temperature: 94
Pest counts: 200
Pest counts: 150
Pest counts: 40
Pest counts: 100
Pest counts: 50
Pest counts: 25
Pest counts: 15
Pest counts: 15
Pest counts: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in incident of raising voice and throwing needle at Resident #65 |
| CMT C | Certified Medication Technician | Witnessed incident between RN B and Resident #65 |
| CNA D | Certified Nurse Aide | Witnessed incident and commented on RN B's behavior |
| Director of Nursing | Director of Nursing | Interviewed regarding staff behavior and incident with RN B |
| Dietary Manager | Dietary Manager | Interviewed regarding food preparation, temperatures, and kitchen cleanliness |
| LPN A | Licensed Practical Nurse | Performed wound care and insulin administration; interviewed about wound care and insulin pen use |
| DON | Director of Nursing | Interviewed about insulin administration, pain management, and infection control |
| ADON | Assistant Director of Nursing | Interviewed about wound care and pressure ulcer prevention |
| CNA K | Certified Nurse Aide | Interviewed about staffing and call light response |
| CNA L | Certified Nurse Aide | Interviewed about staffing and resident care |
| CNA M | Certified Nurse Aide | Interviewed about staffing and resident care |
| CNA O | Certified Nurse Aide | Interviewed about staffing and resident care |
| Administrator | Administrator | Interviewed about staffing, infection control, and immunization policies |
| Social Service Director | Social Service Director | Interviewed about immunization consent process |
| Registered Nurse S | Registered Nurse | Interviewed about insulin vial labeling |
| Licensed Practical Nurse E | Licensed Practical Nurse | Interviewed about insulin pen administration and immunization process |
| Dietary Staff P | Dietary Staff | Interviewed about thawing chicken and kitchen practices |
| Dietary Staff Q | Dietary Staff | Observed not wearing beard restraint |
| Dietary Staff R | Dietary Staff | Observed not wearing beard restraint |
| Pest Control Company | Pest Control Company Representative | Interviewed about pest control program and findings |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about pest control and repair requests |
| Therapy Director | Therapy Director | Interviewed about pressure ulcer prevention and wheelchair cushion |
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