Inspection Reports for Parsons Hill Rehabilitation and Health Care Center
MA, 01603
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% worse than Massachusetts average
Massachusetts average: 7.3 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 19, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding the issuance of Notices of Intent to Discharge to residents prior to their discharge from the facility.
Findings
The facility failed to ensure that three of four sampled residents were provided with a Notice of Intent to Discharge including appeal rights, and that copies were sent to the Office of the State Long-Term Care Ombudsman. The Director of Social Services and Administrator were unaware of these requirements for short term stay residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide required Notices of Intent to Discharge to residents prior to discharge and failure to send copies to the Office of the State Long-Term Care Ombudsman. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Sampled residents: 4
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Services | Interviewed regarding failure to issue Notices of Intent to Discharge to short term stay residents | |
| Administrator | Interviewed regarding unawareness of requirement to issue Notices of Intent to Discharge |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 1, 2025
Visit Reason
The inspection was conducted following complaints from residents about rude and aggressive behavior by a Certified Nurse Aide (CNA #1) on the 3:00 P.M. to 11:00 P.M. shift, which was initially considered a customer service issue but later determined to be an abuse allegation.
Findings
The facility failed to ensure residents were treated with respect and dignity, as multiple residents reported that CNA #1 was rude, aggressive, yelled at them, and was mean, leading residents to avoid requesting assistance from her. The facility conducted an internal investigation and terminated CNA #1's employment based on findings of abusive behavior.
Complaint Details
The complaint investigation was substantiated as an abuse allegation after resident interviews and facility investigation confirmed CNA #1's rude, aggressive, and disrespectful behavior toward residents, resulting in CNA #1's termination.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in multiple resident complaints and facility investigation for rude and aggressive behavior. |
| Director of Social Services | Conducted resident interviews related to CNA #1's behavior. | |
| Activities Director | Reported resident concerns about CNAs to administration. | |
| Administrator | Determined the complaint as an abuse allegation and terminated CNA #1. | |
| Assistant Director of Nurses | ADON | Reported on the process of complaint evaluation and resident interviews. |
| Nurse #2 | Nurse | Reported CNA #1's rude behavior and attempts to redirect her. |
| CNA #4 | Certified Nurse Aide | Reported CNA #1's rough and abrupt behavior. |
Inspection Report
Routine
Deficiencies: 11
Mar 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, safety, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medication, failure to provide required Medicare non-coverage notices, unsafe environmental conditions, inaccurate resident assessments, failure to coordinate vision care, improper enteral feeding labeling, incorrect oxygen therapy settings, inadequate dialysis communication, failure to implement pharmacist recommendations, improper infection control practices, and ineffective pest control measures.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Level of Harm - Potential for minimal harm: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to obtain informed consent for psychotropic medication (Clonidine) for Resident #205. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide paper copy of Notice of Medicare Non-Coverage to Resident #130's responsible party. | Level of Harm - Potential for minimal harm |
| Failed to repair hole in wall behind Resident #3's bed and enclose exposed pipes on Burncoat Unit. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately complete Minimum Data Set assessments for Residents #49 and #67. | Level of Harm - Potential for minimal harm |
| Failed to coordinate vision care services for Resident #129 who requested and consented to vision care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label and date enteral feeding bags for Resident #116 as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure oxygen concentrator was set at prescribed 2 LPM for Resident #91; observed at 1.5 LPM. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide ongoing dialysis communication and documentation for Residents #93 and #147. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement Consultant Pharmacist recommendations timely for Residents #116, #122, and #49. | Level of Harm - Minimal harm or potential for actual harm |
| Housekeeping staff failed to adhere to infection control standards including proper PPE use and hand hygiene on Greendale Unit. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement effective pest control program; live mice observed in resident rooms and exterminator services suspended for two months. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Sample size: 29
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 9
Dead mice found: 14
Dead mice found: 8
Rodent glue traps replaced: 20
Dead mice found: 10
Rodent glue traps replaced: 60
Tin cat traps missing: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #2 | Interviewed about hole in wall and exposed pipes on Burncoat Unit | |
| Assistant Director of Nurses (ADON) | Interviewed about missing informed consent for psychotropic medication and vision care coordination | |
| Unit Manager (UM) #1 | Interviewed about missing informed consent for psychotropic medication | |
| Director of Nursing (DON) | Interviewed about missing informed consent, vision care coordination, oxygen therapy, and pharmacist recommendations | |
| MDS Nurse #2 | Interviewed about failure to mail NOMNC form | |
| MDS Nurse #3 | Interviewed about inaccurate MDS coding for antidepressant | |
| Nurse #1 | Interviewed about enteral feeding labeling | |
| Unit Manager (UM) #2 | Interviewed about dialysis communication | |
| Regional Maintenance Director (RMD) | Interviewed about pest control and exterminator services | |
| Exterminator | Interviewed about pest control services and trap counts | |
| Housekeeper #1 | Observed and interviewed about improper PPE use and hand hygiene | |
| Infection Preventionist (IP) | Interviewed about housekeeping PPE and hand hygiene deficiencies | |
| Activities Director (AD) | Interviewed about Resident Council response to pest control | |
| Administrator | Interviewed about pest control contract and Quality Improvement Plan |
Inspection Report
Routine
Census: 148
Deficiencies: 2
Jul 23, 2024
Visit Reason
The inspection was conducted to assess compliance with nursing staffing requirements and the accuracy and completeness of resident medical records, including care plans and documentation by Certified Nurse Aides.
Findings
The facility failed to ensure the Director of Nurses did not serve as a charge nurse when census exceeded 60 residents, and failed to maintain complete and accurate medical records for a resident requiring supervision with eating, as CNAs documented the resident as independent and the CNA Care Card was incomplete.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Director of Nurses served as a charge nurse on a unit when daily occupancy was greater than 60 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete and accurate medical records for Resident #1, including incomplete CNA Care Card and inaccurate documentation of eating supervision needs. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility Census: 148
Shifts coded as independent for eating: 12
Applicable shifts reviewed: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding documentation of Resident #1's eating supervision |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding documentation of Resident #1's eating supervision |
| Certified Nurse Aide #3 | Certified Nurse Aide | Interviewed regarding use of CNA Care Card for newly admitted residents |
| Certified Nurse Aide #4 | Certified Nurse Aide | Interviewed regarding use of CNA Care Card for newly assigned residents |
| Assistant Director of Nurses | Assistant Director of Nurses | Interviewed about DON working night shift due to staffing shortages |
| Administrator | Administrator | Interviewed about DON working night shift due to low nurse staffing |
| Director of Nurses | Director of Nurses | Interviewed regarding completion of CNA Care Card and supervision requirements for Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 16
Jan 17, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident dignity and respect, abuse prevention, accurate resident assessments, care planning, activity provision, dialysis care, nutritional care, medical record accuracy, infection control, and vaccination procedures at Parsons Hill Rehabilitation & Health Care Center.
Findings
The facility failed to ensure resident dignity and respect, prevent abuse and retaliation, accurately complete resident assessments, develop and implement timely care plans, provide scheduled activities, ensure dialysis care and emergency preparedness, maintain accurate medical records, provide adequate nutritional care, maintain infection control especially regarding rodent infestation, and ensure pneumococcal vaccinations were offered and documented properly.
Complaint Details
The complaint investigation revealed multiple deficiencies related to resident dignity, abuse prevention, care planning, activity provision, dialysis care, nutritional care, medical record accuracy, infection control, vaccination, staffing, and staff competency.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 16
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure one Resident (#40) was treated with dignity and respect; staff failed to intervene when other residents yelled and used profane language at Resident #40. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prohibit and prevent abuse and retaliation for Residents #77 and #248; staff failed to intervene when Resident #248 threatened Resident #77 after law enforcement involvement. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate Minimum Data Set (MDS) assessments for six residents (#97, #141, #39, #40, #24, #13), including inaccurate coding of dialysis, continence, diagnoses, and medication use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to re-submit a Level 1 PASARR for Resident #15 after diagnosis of Undifferentiated Schizophrenia was added. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement timely fall prevention and trauma informed care plans for Residents #66 and #28. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide scheduled activities and alert Residents #12, #40, and #248 of activity schedule changes; failed to invite them to participate in food social activity. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide proper assistive devices for hearing for Resident #28; no follow-up on audiology recommendation for hearing aids. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate nutritional care for Resident #79; failed to identify and address significant unplanned weight loss and failed to ensure re-weigh and timely intervention. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate dialysis care for Resident #102; failed to monitor and document fluid intake as ordered and failed to provide emergency supplies including non-serrated clamps at bedside. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nursing staff competencies were completed for three licensed nurses (Unit Manager #2, Nurse #5, Nurse #6) to provide safe nursing care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to meet nutritional needs of Resident #348; failed to communicate and implement Registered Dietitian's recommendation to add additional sandwiches for weight gain. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain accurate medical records for Residents #130 and #141; inaccurate documentation of oxygen tubing changes and foley catheter changes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a safe, sanitary environment and control rodent infestation on the Tatnuck Unit; rodent droppings were present in rooms of Residents #115, #12, and #248 and cleaning methods did not follow CDC guidelines. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pneumococcal vaccine was offered and/or administered to Residents #87 and #123 despite eligibility, placing them at risk for pneumonia. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide coverage by a Registered Nurse for at least eight consecutive hours on 1/1/2024 as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete annual performance reviews and provide in-service education for CNAs #6 and #7 since 2019. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 31
Resident #40 sample size: 1
Resident #77 and #248 sample size: 2
Residents with inaccurate MDS: 6
Resident #66 falls: 2
Resident #79 weight loss: 12.8
Resident #130 oxygen tubing change date: Jan 10, 2024
Resident #141 foley catheter size: 16
Resident #102 dialysis fluid restriction: 1500
Resident #102 dialysis fluid allocation per shift: 340
Resident #102 dialysis fluid allocation per shift: 190
Resident #102 dialysis dietary allowance: 630
Resident #102 dialysis Nepro servings: 3
Resident #102 dialysis Nepro serving size: 237
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #5 | Certified Nurse Aide | Named in dignity and respect deficiency related to Resident #40 |
| Nurse #4 | Nurse | Named in dignity and respect deficiency and activity provision |
| Administrator | Interviewed regarding staff desensitization and failure to intervene | |
| Nurse #3 | Certified Nurse Aide | Observed during Resident #40 and #12 yelling incident |
| CNA #4 | Certified Nurse Aide | Observed during Resident #248 verbal threats incident |
| Nurse #2 | MDS Nurse | Interviewed regarding MDS assessment inaccuracies |
| Social Worker #1 | Social Worker | Interviewed regarding PASARR and trauma screening |
| Director of Nurses | Director of Nurses | Interviewed regarding abuse prevention, MDS, weight loss, dialysis care, and staff competencies |
| Activities Director | Activities Director | Interviewed regarding activity provision failures |
| Activities Assistant #1 | Activities Assistant | Interviewed regarding activity schedule changes |
| Unit Manager #1 | Unit Manager | Interviewed regarding medical record inaccuracies |
| Unit Manager #2 | Unit Manager | Interviewed regarding dialysis care and medical record inaccuracies |
| Nurse #5 | Nurse | Named in staff competency deficiency |
| Nurse #6 | Nurse | Named in staff competency deficiency |
| Dietitian | Registered Dietitian | Interviewed regarding nutritional care deficiencies |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding rodent infestation and cleaning practices |
| Maintenance Director | Maintenance Director | Interviewed regarding rodent infestation and pest control |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control and rodent cleaning procedures |
| Scheduler | Scheduler | Interviewed regarding RN staffing coverage |
| Staff Development Coordinator | Staff Development Coordinator | Interviewed regarding staff competency training |
Inspection Report
Complaint Investigation
Deficiencies: 3
Apr 19, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to ensure residents had access to their personal funds on weekends and concerns about inadequate supervision leading to a resident eloping from the facility.
Findings
The facility failed to implement its policy on Patient/Resident Trust Accounts, restricting residents' access to funds on weekends. Additionally, the facility failed to provide adequate supervision to prevent a resident at risk for elopement from leaving unattended, resulting in the resident leaving the facility via taxi without staff knowledge or approval.
Complaint Details
The complaint investigation focused on Resident #1, who was at risk for elopement and required supervision. On 04/01/23, Receptionist #1 called a taxi for Resident #1 and allowed him/her to leave the facility unattended without notifying nursing staff or checking the elopement risk binder. Resident #1 was missing for over four hours before being located by police at a shopping center and returned unharmed. The facility failed to follow care plan interventions and policies related to elopement risk and leave of absence orders.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure residents had access to their personal funds on weekends as per facility policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a complete care plan that meets all the resident's needs, including supervision to prevent elopement. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate supervision to prevent accidents, including elopement, resulting in a resident leaving the facility unattended. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents with Resident Trust Accounts: 95
Resident #1 BIMS score: 14
Time resident missing: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Receptionist #1 | Receptionist | Called a taxi for Resident #1 and allowed the resident to leave unattended without notifying nursing staff or checking elopement risk. |
| Nurse #1 | Nurse | Assigned nurse for Resident #1 who was not notified before the resident left the facility unattended. |
| Director of Nurses | Director of Nurses (DON) | Provided interviews regarding Resident #1's cognitive status, care plan, and the failure of staff to follow procedures. |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) | Reviewed surveillance footage and participated in locating Resident #1 after elopement. |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Reported last seeing Resident #1 before elopement and described resident's behavior and language barrier. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 15, 2023
Visit Reason
The inspection was conducted to investigate compliance with policies related to annual influenza vaccinations and COVID-19 outbreak testing following complaints or concerns regarding these areas.
Findings
The facility failed to ensure annual influenza vaccination was offered to Resident #4 or their legal guardian for the 2022 influenza season, and failed to conduct COVID-19 outbreak testing every 48 hours for Residents #6 and #8 during an active outbreak, as required by facility policy.
Complaint Details
The visit was complaint-related, focusing on failure to offer influenza vaccination and inadequate COVID-19 outbreak testing. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure staff offered the annual influenza vaccination to Resident #4 or Resident Representative as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff conducted COVID-19 outbreak testing every 48 hours for Residents #6 and #8 during an active outbreak. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for influenza vaccination: 5
Residents sampled for COVID-19 testing: 3
Residents affected by influenza vaccination deficiency: 1
Residents affected by COVID-19 testing deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Interviewed regarding influenza vaccination policy and COVID-19 testing documentation | |
| Assistant Director of Nurses | Interviewed regarding COVID-19 outbreak testing procedures and deficiencies |
Inspection Report
Routine
Deficiencies: 15
Jul 11, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to accurately identify and document residents' advance directives, failure to notify physicians and healthcare proxies of changes in residents' conditions, inadequate investigation of resident-to-resident altercations, failure to encode and transmit discharge assessments, incomplete fall risk assessments and care plans, failure to assist residents with assistive devices, inadequate wound care, improper medication self-administration assessments, failure to ensure safe smoking practices with nicotine patches, improper scheduling of medications around dialysis, lack of emergency kits at dialysis bedside, failure to document pharmacist recommendations, and inadequate dining space and furnishings.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Potential for minimal harm: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure staff accurately identified advance directives for Resident #119. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify physician and obtain orders for treatment of a wound for Resident #71. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify physician of missed medication doses for Resident #151 and failed to notify healthcare proxy of Resident #119's change in condition after a fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to investigate and report a resident-to-resident altercation involving Resident #10. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to encode and transmit discharge Minimum Data Set assessments for five residents. | Level of Harm - Potential for minimal harm |
| Failed to complete fall evaluation assessment and accurately reflect fall history for Resident #23. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a baseline care plan within 48 hours of admission for Resident #119. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assist Resident #133 in obtaining an assistive listening device for hearing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate wound care and notify physician for Resident #71's left hand wound. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop care plan and provide adequate supervision to prevent falls for Resident #119; failed to assess Resident #28 for safe self-administration of topical medication; failed to ensure Resident #91 did not smoke while wearing nicotine patch. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care related to oxygen tubing labeling and changing for Resident #10. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to manage medication scheduling around dialysis for Resident #71 and failed to ensure emergency kit was available at bedside for Resident #9 receiving dialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document physician review and action on pharmacist drug regimen recommendations for Residents #49 and #51. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement dietary plan of care to provide almond milk as ordered for Resident #9. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate dining space and furnishings on the Transitional Care Unit. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 30
Residents affected: 5
Wound size: 3
Wound size: 2.1
BIMS score: 14
BIMS score: 10
BIMS score: 15
BIMS score: 15
BIMS score: 15
Medication doses missed: 2
Fall incidents: 3
Medication dose: 10
Medication dose: 200
Medication dose: 100
Medication dose: 50
Medication dose: 325
Medication dose: 25
Medication dose: 24
Medication dose: 14
Medication dose: 3
Residents on TCU: 30
Chairs at rectangular table: 6
Wobbly chairs: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #2 | Interviewed about Resident #119's code status and medication administration | |
| Director of Nursing | DON | Interviewed about multiple deficiencies including Resident #119's advance directives and medication issues |
| Nurse #6 | Interviewed about wound care for Resident #71 | |
| Nurse #8 | Interviewed about wound care and medication administration | |
| Social Worker #1 | SW | Interviewed about notification of healthcare proxy for Resident #119 |
| Unit Manager #1 | UM | Interviewed about fall care plans and emergency kit availability |
| Nurse #5 | Interviewed about Resident #133's hearing assistive device | |
| Nurse #3 | Interviewed about Resident #91's nicotine patch and smoking | |
| Nurse #7 | Interviewed about oxygen tubing labeling for Resident #10 | |
| Nurse #1 | Interviewed about emergency kit availability and medication administration | |
| Assistant Director of Nursing | ADON | Interviewed about multiple deficiencies including medication administration and hearing device |
| Certified Nurse Aide #2 | CNA | Interviewed about dining area usage |
| Maintenance Staff #1 | Interviewed about dining area furniture and storage of IV poles |
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