Inspection Reports for Pleasant Valley Healthcare Rehabilitation Center
TX, 75040
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
234% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 1
Dec 19, 2025
Visit Reason
The inspection was conducted to assess compliance with care and treatment standards following observations, interviews, and record reviews related to a resident's untreated rash and overall quality of care.
Findings
The facility failed to ensure timely assessment and treatment of a resident's rash over several days, resulting in delayed treatment orders. This failure posed a risk to residents with skin conditions, potentially leading to worsening skin issues and decreased health and psychosocial well-being.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically delayed follow-up and treatment of a resident's rash. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication dosage: 25
Treatment duration: 10
BIMS Score: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Named in failure to follow up on resident's rash and documentation of rash on 12/17/25 |
| LVN C | Licensed Vocational Nurse | Named in failure to follow up on resident's rash and documentation of rash on 12/16/25 |
| LVN E | Licensed Vocational Nurse | Named in failure to follow up on resident's rash and documentation of rash on 12/18/25 |
| Treatment Nurse F | Treatment Nurse | Assessed resident on 12/18/25 and called NP for treatment orders |
| NP G | Nurse Practitioner | Provided treatment orders for nystatin and Benadryl on 12/18/25 |
| LVN A | Licensed Vocational Nurse | Assessed resident on 12/19/25 and applied treatment |
| LVN D | Licensed Vocational Nurse | Worked 12/16/25 shift, involved in communication about rash monitoring |
| DON | Director of Nursing | Provided statements regarding rash treatment and nurse documentation |
| Administrator | Facility Administrator | Provided statements regarding nurse responsibilities and rash treatment |
Inspection Report
Routine
Deficiencies: 5
Apr 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, PASRR screenings, incontinence care, food service safety, and hand hygiene practices at Pleasant Valley Healthcare and Rehabilitation Center.
Findings
The facility failed to ensure accurate PASRR Level I screening for one resident, timely treatment of a urinary tract infection for another resident, proper incontinence care for a resident, and appropriate food service hygiene practices in the kitchen. These deficiencies posed risks of inadequate specialized services, delayed treatment, infection, and foodborne illness.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure the accuracy of the PASRR Level I screen for Resident #51, resulting in no PASRR Level II assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident #43 received immediate treatment after reporting symptoms of a urinary tract infection, resulting in increased pain and delayed antibiotic administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate incontinence care for Resident #22, including double-briefing and inadequate cleansing of the vaginal area. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to utilize proper personal hygiene practices in the kitchen, including improper glove use, risking contamination of food. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow hand hygiene procedures consistently among staff to prevent spread of infection. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Named in delayed treatment and documentation failure for Resident #43's urinary tract infection | |
| LVN B | Named in delayed treatment and assessment of Resident #43's urinary tract infection | |
| CNA N | Named in double-briefing Resident #22 and inadequate incontinence care | |
| CNA O | Named in inadequate cleansing during incontinence care for Resident #22 | |
| Physician | Named in delayed assessment and treatment of Resident #43's urinary tract infection | |
| MDS Nurse | Named in inaccurate PASRR Level I screening for Resident #51 | |
| DON | Director of Nursing | Named in interviews regarding Resident #51 PASRR screening and Resident #43 care |
| Dietary Manager | Named in kitchen hygiene and food safety interviews | |
| Dietary Aide R | Named in kitchen hygiene and glove use interviews | |
| Cook Q | Named in kitchen hygiene observation |
Inspection Report
Routine
Deficiencies: 6
Apr 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to PASARR screenings, quality of care, incontinence care, dietary services, food safety, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including inaccurate PASARR Level I screening for a resident, delayed treatment of a urinary tract infection, inadequate incontinence care, failure to follow dietary recipes and food safety protocols, improper hand hygiene and infection control practices by staff, and failure to provide palatable and properly prepared food.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure the PASARR Level I assessment accurately reflected the resident's status and did not complete a required PASRR Level II evaluation for Resident #51. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident #43 received timely treatment for urinary tract infection symptoms, resulting in increased pain and delayed antibiotic administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate incontinence care for Resident #22, including double-briefing and inadequate cleansing of the vaginal area. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide palatable, attractive, and appetizing food and drink; did not follow recipes accurately in food preparation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain proper food service safety practices including improper glove use and hand hygiene in the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an infection control program; staff administered medication with bare hands and failed to perform hand hygiene during incontinence care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 77
Residents affected: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MA K | Used ungloved hand to pick medication from medication cart and administered it to Resident #30 | |
| CNA L | Failed to perform hand hygiene while providing incontinence care to Resident #180 | |
| LVN A | Nurse assigned to Resident #43 who delayed treatment for urinary tract infection | |
| LVN B | Nurse who administered antibiotic to Resident #43 and reported complaint to physician | |
| MDS Nurse | Interviewed regarding inaccurate PASARR Level I screening for Resident #51 | |
| DON | Director of Nursing | Interviewed regarding PASARR screening and infection control expectations |
| Physician | Physician for Resident #43 involved in delayed treatment of urinary tract infection | |
| CNA N | Failed to avoid double-briefing Resident #22 | |
| CNA O | Failed to thoroughly cleanse Resident #22's vaginal area during incontinence care | |
| Cook Q | Failed to follow recipes and proper food preparation procedures | |
| Dietary Manager | Oversaw dietary services and acknowledged recipe guidelines | |
| Dietitian | Oversaw dietary assessments and therapeutic diets | |
| Dietary Aide R | New employee who acknowledged importance of following recipes and glove use |
Inspection Report
Complaint Investigation
Deficiencies: 4
Sep 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide safe and appropriate dialysis care/services for a resident requiring such services, specifically Resident #1.
Findings
The facility failed to ensure that Resident #1 received dialysis services as ordered, failed to notify the resident's doctor or nurse practitioner about dialysis center instructions, and failed to properly assess and document vital signs before and after dialysis. Resident #1 experienced a cardiac arrest and subsequent death following these failures. Documentation and communication deficiencies were also noted.
Complaint Details
The investigation was complaint-driven, focusing on Resident #1's dialysis care failures, including failure to dialyze, failure to notify medical providers, and failure to document vital signs and communication. The complaint was substantiated with findings of immediate jeopardy and subsequent removal of immediate jeopardy status.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide safe, appropriate dialysis care/services for Resident #1 requiring dialysis. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to document Resident #1's vital signs check in the EMR before leaving and after returning from dialysis on the date of incident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document special instructions from Dialysis Center for Resident #1 to go to hospital for permacath placement. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document notifying Resident #1's Doctor/NP about the need to go to hospital per Dialysis Communication sheet and outcome. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Dialysis frequency: 3
Blood pressure: 14563
Vital signs: 124
Lab values: 22.5
Lab values: 8.8
Lab values: 9
Lab values: 140
Lab values: 280
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Failed to notify Resident #1's Doctor/NP about dialysis center instructions, failed to assess and document vital signs before and after dialysis, misplaced vital signs documentation. |
| ADON D | Assistant Director of Nursing | Noticed Resident #1 unresponsive, initiated CPR, involved in code blue response. |
| FM P | Family member who was involved in communication about Resident #1's dialysis and hospital transfer. | |
| DON | Director of Nursing | Oversaw nursing care, confirmed dialysis vital sign protocols, involved in staff training and investigation. |
| Dialysis Nurse | Provided dialysis communication forms, informed family member about Resident #1's access port issues and hospital transfer. | |
| Administrator | Provided statements regarding incident, staff documentation, and facility policies. |
Inspection Report
Routine
Deficiencies: 4
Mar 14, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights, pharmaceutical services, resident council privacy, and facility administration management.
Findings
The facility failed to accommodate a resident's need for a soft touch call light, failed to provide a private meeting space for resident council meetings, had discrepancies and expired medications on a medication cart, and lacked a properly licensed administrator actively managing the facility.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure Resident #16 was accommodated with a soft touch call light to meet her needs for calling assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a private meeting space for resident council meetings for 13 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide accurate narcotic records and remove expired medications on the hall 400 nurses' medication cart affecting Residents #16 and #37. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to appoint a properly licensed administrator responsible for managing the facility; the identified Administrator was not actively involved in day-to-day operations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for Resident Rights: 8
Residents reviewed for resident council: 13
Residents reviewed for pharmacy services: 2
BIMS Score Resident #16: 4
BIMS Score Resident #37: 0
Medication count Resident #16: 55
Medication count Resident #37: 7
Expired medication date: 2024.02
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Facility Administrator | Identified Administrator not actively involved in day-to-day operations; responsible for overseeing facility |
| Operations Manager | Operations Manager | Managed facility operations pending Administrator licensing; responsible for ANE reporting |
| DON | Director of Nursing | Responsible for nursing staff education and narcotic administration oversight |
| LVN E | Licensed Vocational Nurse | Observed medication cart discrepancies and educated Resident #16 on soft touch call light |
| RN G | Registered Nurse | Night shift nurse who administered narcotics and logged medication |
| ADON | Assistant Director of Nursing | Discussed responsibilities for medication administration and narcotic log monitoring |
| OT B | Occupational Therapist | Evaluated Resident #16 and agreed on need for soft touch call light |
| CNA C | Certified Nursing Assistant | Cared for Resident #16 and unaware of call light issue until survey |
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 21, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Pleasant Valley Healthcare and Rehabilitation Center.
Findings
No health deficiencies were found during the inspection, indicating full compliance with applicable standards.
Inspection Report
Complaint Investigation
Deficiencies: 3
Nov 24, 2023
Visit Reason
The inspection was conducted due to allegations of neglect and failure to provide necessary care to residents, including a resident suicide and inadequate incontinence care.
Findings
The facility failed to protect residents from neglect, resulting in serious harm including a resident suicide. Staff failed to provide necessary oversight and care, including incontinence care, and did not follow abuse and neglect prevention policies. Immediate Jeopardy was identified but later lowered with ongoing monitoring and corrective actions.
Complaint Details
The complaint investigation was substantiated with findings of neglect resulting in serious harm including a resident suicide. Immediate Jeopardy was identified and later lowered after corrective actions were implemented.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress to residents, including a resident suicide. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to implement written policies and procedures to prevent abuse, neglect, and theft, and failure to immediately remove or suspend staff involved in neglect during investigation. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure staff implemented abuse and neglect policies and procedures during provision of care and services to residents. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents reviewed for neglect: 9
Residents affected: 5
Shift hours: 8
PHQ-9 score: 10
BIMS score: 11
BIMS score: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in neglect and failure to provide oversight during the shift when Resident #1 committed suicide. |
| CNA C | Certified Nursing Assistant | Named in neglect and failure to provide necessary care during the shift when Resident #1 committed suicide. |
| LVN B | Licensed Vocational Nurse | Discovered Resident #1 deceased and called 911. |
| PNFA | Pending Nursing Facility Administrator | Involved in investigation and reporting of the incident. |
| ADON | Assistant Director of Nursing | Present at time Resident #1 was discovered and involved in incident response. |
| DON | Director of Nursing | Provided oversight and education related to abuse and neglect policies. |
| LCSW | Licensed Clinical Social Worker | Provided psych consultation services to Resident #1. |
| Hospice CM | Hospice Case Manager | Admitted Resident #1 to hospice and involved in care coordination. |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 11, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Pleasant Valley Healthcare and Rehabilitation Center.
Findings
No health deficiencies were found during the inspection, indicating full compliance with applicable standards.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation related to Resident #1 regarding the facility's failure to permit the resident to remain in the facility and improper transfer/discharge procedures.
Findings
The facility failed to provide adequate reasons and documentation for discharging Resident #1, who had complex medical needs and was totally dependent on staff. The resident's representative (RP) reported multiple concerns including improper care, clogged feeding tube incidents, and aggressive behavior accusations leading to visitation restrictions and a 30-day discharge notice. The facility cited interference by the RP with medical care and threats to staff as reasons for discharge, but evidence to support these claims was limited. The discharge was ultimately due to the facility's inability to meet the resident's needs given the family dynamics and care disagreements.
Complaint Details
The complaint investigation focused on Resident #1's discharge initiated by the facility without adequate justification. The RP alleged retaliation and improper care, including clogged feeding tubes and dressing changes done by the RP due to facility neglect. The facility cited interference by the RP with medical care and threatening behavior as reasons for discharge. The RP disputed these claims and reported feeling pressured and traumatized by the discharge process. The investigation included interviews with the RP, facility administration, nursing staff, and review of clinical records and correspondence.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to not transfer or discharge a resident without an adequate reason and without providing documentation and specific information when a resident is transferred or discharged. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
30-day discharge notice: 30
Dates of incidents and correspondence: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MD A | Attending Physician | Physician who documented inability to provide care due to family interference and authored discharge letter. |
| RN B | Nurse | Nurse involved in care during clogged feeding tube incident and reported threatened by family member. |
| RN C | Nurse | Nurse who assisted during dressing change incident and was reportedly unsure how to secure catheter properly. |
| ADM | Administrator | Facility administrator involved in discharge decision, visitation restrictions, and interviews. |
| DON | Director of Nursing | Nursing director involved in care decisions, family education, and interviews. |
| SW | Social Worker | Social worker involved in discharge planning and interviews. |
Inspection Report
Deficiencies: 1
May 5, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food service safety standards, specifically focusing on kitchen sanitation practices.
Findings
The facility failed to properly sanitize the temperature gauge after each use during food temperature checks, which could place residents at risk for food contamination and food-borne illness. Staff acknowledged the failure and the risks involved, and the facility had not provided dietary policies regarding sanitizing and temperature checks before exit.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Cook A failed to sanitize the temperature gauge after each use, risking food contamination and food-borne illness. | Level of Harm - Minimal harm or potential for actual harm |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 21, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Pleasant Valley Healthcare and Rehabilitation Center, summarizing the findings of a regulatory survey completed on 2023-04-21.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 3
Feb 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, and infection prevention and control at Pleasant Valley Healthcare and Rehabilitation Center.
Findings
The facility failed to ensure accurate resident assessments and care plans, specifically failing to reflect Resident #4's oxygen use and Resident #3's ostomy care. Additionally, the facility failed to maintain proper infection control practices, as evidenced by a staff member not wearing a mask properly in a patient care area.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure Resident #4's MDS Assessments accurately reflected his use of oxygen. | 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 accurate reflection of Resident #3's ostomy and Resident #4's oxygen use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an infection control policy and procedure, with LVN A failing to wear her mask over her mouth and nose in a patient care area. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for assessments: 6
Residents reviewed for care plan accuracy: 5
Staff reviewed for infection control: 13
Oxygen administration rate: 4
Oxygen order range: 2
Oxygen order range: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in infection control deficiency for failing to wear mask properly |
| LVN D | Licensed Vocational Nurse | Interviewed regarding Resident #4's continuous oxygen use |
| CNA B | Certified Nursing Assistant | Interviewed regarding observation of Resident #4's oxygen use |
| CNA C | Certified Nursing Assistant | Interviewed regarding Resident #4's oxygen use |
| DON | Director of Nursing | Interviewed regarding expectations for MDS accuracy and care plans |
| MDS Nurse | Interviewed regarding MDS assessment process and care plan responsibilities |
Inspection Report
Routine
Deficiencies: 3
Feb 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, and infection prevention and control.
Findings
The facility failed to ensure accurate resident assessments and care plans for oxygen use and ostomy management for specific residents, and failed to maintain proper infection control practices, including staff mask usage.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure Resident #4's MDS Assessments accurately reflected his use of oxygen. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to review and revise the person-centered care plan to reflect current code status for Resident #3 and Resident #4, specifically regarding ostomy and oxygen use. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain an infection control policy and procedure designed to provide a safe environment; LVN A failed to wear her mask over mouth and nose in a patient care area. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for assessments: 6
Residents reviewed for care plan accuracy: 5
Staff reviewed for infection control: 13
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in infection control deficiency for failing to wear mask properly |
| DON | Director of Nursing | Interviewed regarding MDS accuracy and care plan expectations |
| MDS Nurse | Interviewed regarding MDS assessment process and care plan responsibilities | |
| CNA B | Certified Nursing Assistant | Interviewed regarding Resident #4 oxygen use |
| CNA C | Certified Nursing Assistant | Interviewed regarding Resident #4 oxygen use |
| LVN D | Licensed Vocational Nurse | Interviewed regarding Resident #4 oxygen use |
Inspection Report
Annual Inspection
Deficiencies: 4
Jan 19, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, drug storage, food safety, and infection control at Pleasant Valley Healthcare and Rehabilitation Center.
Findings
The facility failed to maintain medication error rates below 5%, failed to securely store medications for some residents, failed to ensure food safety by proper labeling and expiration checks, and failed to maintain proper infection prevention practices including hand hygiene during resident care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure medication error rates were below 5%, with a 13% medication administration error rate due to late medication administration by staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure all drugs and biologicals were stored in locked compartments for two residents who had medications at bedside. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, prepare, distribute, and serve food in accordance with professional standards, including expired and unlabeled food items in the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide and implement an infection prevention and control program, including failure of staff to perform proper hand hygiene before and after perineal care of a resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication opportunities: 36
Medication administration error rate: 13
Expired food items: 3
Hamburger patties: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MA C | Named in medication administration error finding for administering late medications | |
| RN D | Registered Nurse | Interviewed regarding medication storage and administration |
| LVN B | Licensed Vocational Nurse | Interviewed regarding medication storage and infection control practices |
| CNA A | Certified Nursing Assistant | Named in infection control deficiency for failure to perform proper hand hygiene |
| DON | Director of Nursing | Interviewed regarding medication administration policy and infection control |
| Dietary Manager | Interviewed regarding food safety and kitchen practices | |
| AM [NAME] | Assistant Manager | Interviewed regarding food safety and kitchen practices |
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