Deficiencies (last 4 years)
Deficiencies (over 4 years)
16.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
259% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
36
27
18
9
0
Census
Latest occupancy rate
129 residents
Based on a November 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 129
Deficiencies: 3
Date: Nov 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints regarding failure to notify resident representatives of room changes, unsecured hazardous areas, and medication administration errors.
Complaint Details
The deficiencies represent non-compliance investigated under Complaint Numbers 2646189 (room change notification), 2651378 (hazardous areas), and 2661530 (medication administration).
Findings
The facility failed to notify resident representatives of room changes affecting one resident, failed to secure hazardous areas on the memory care unit potentially affecting 25 residents, and failed to ensure timely administration of intravenous antibiotics to one resident due to billing and authorization delays.
Deficiencies (3)
Failed to ensure resident representatives received notification of room change affecting one resident.
Failed to ensure hazardous areas and materials were properly secured on the memory care unit, potentially affecting 25 residents.
Failed to ensure timely administration of intravenous antibiotics resulting in a significant medication error affecting one resident.
Report Facts
Residents affected: 1
Residents affected: 25
Residents affected: 1
Facility census: 129
Medication dosage: 1.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #459 | Licensed Practical Nurse | Discovered bed bugs and notified prior DON but did not notify family about room change |
| LPN #477 | Licensed Practical Nurse | Reported issues with antibiotic availability and communicated with infectious disease specialist |
| Hospital Case Manager #497 | Communicated antibiotic options and authorization with facility staff | |
| Admission/Marketing #445 | Communicated with hospital case manager and facility staff regarding antibiotic authorization | |
| Housekeeping Supervisor #265 | Housekeeping Supervisor | Verified unlocked clean utility room and accessibility of chemicals |
| Pharmacy Technician #504 | Pharmacy Technician | Provided information on antibiotic dosages and medication delays |
| Director of Nursing (DON) | Director of Nursing | Notified about medication authorization delays and apologized for poor communication regarding room change |
| Nurse Practitioner (NP) #501 | Nurse Practitioner | Confirmed lack of notification about room change |
| Nurse Practitioner (NP) #500 | Nurse Practitioner | Confirmed lack of notification about room change |
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 1
Date: Oct 14, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely assess and obtain necessary treatment for Resident #207's urinary tract infection.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number 2637235.
Findings
The facility failed to promptly address Resident #207's urinary tract infection symptoms, with delays in ordering and obtaining a urine specimen and initiating antibiotic treatment. Documentation and communication regarding the resident's symptoms and family concerns were inadequate.
Deficiencies (1)
Failure to timely assess and obtain necessary treatment for Resident #207's urinary tract infection.
Report Facts
Facility census: 127
Days delay in antibiotic order: 12
Days delay in urine specimen collection: 3
Residents reviewed for urinary tract infection: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #333 | Notified nursing coordinator of concerns but did not document or order urinalysis timely | |
| Director of Nursing | Verified lack of documentation and delay in addressing symptoms |
Inspection Report
Complaint Investigation
Census: 124
Capacity: 124
Deficiencies: 7
Date: Sep 11, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by concerns regarding water temperatures, linen availability, garbage disposal, care plan comprehensiveness, care plan meetings, medication administration, blood pressure monitoring, meal service timeliness, infection control, and boiler system functionality.
Complaint Details
The complaint investigation was initiated due to multiple concerns including inadequate hot water temperatures, insufficient linens and garbage bags, incomplete care plans, delayed or absent care plan meetings, failure to follow physician orders for blood pressure monitoring, late meal service, improper medication handling, and malfunctioning boiler systems.
Findings
The facility failed to maintain adequate hot water temperatures affecting resident bathing, failed to provide sufficient clean linens and garbage bags, lacked comprehensive anticoagulant care plans for certain residents, did not offer timely or in-person care plan meetings as requested, failed to follow physician orders for blood pressure monitoring and notification, served meals late on the Memory Care Unit, improperly handled medication administration, and had malfunctioning boiler systems impacting hot water availability.
Deficiencies (7)
Failed to ensure water temperatures were maintained at a comfortable level for resident bathing/showers, failed to maintain an adequate supply of clean bath linens, and failed to ensure garbage bags were available in resident rooms.
Failed to develop and implement complete care plans for anticoagulant therapy for three residents.
Failed to offer care plan meetings timely, per preference, and in person for one resident.
Failed to ensure physician orders were followed and physician was notified of elevated blood pressure readings for one resident.
Failed to ensure meals were served timely on the Memory Care Unit affecting 33 residents.
Failed to implement infection control procedures during medication administration for one resident.
Failed to keep all essential equipment working safely; boiler systems were not functional and operational, affecting hot water availability for all residents.
Report Facts
Residents affected: 11
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 33
Facility census: 124
Boilers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #378 | CNA | Reported no hot water on Memory Care Unit affecting shower assistance |
| Mechanical Contractor #505 | Mechanical Contractor | Confirmed hot water temperatures were not correct and provided quote to replace boilers |
| Licensed Practical Nurse #337 | LPN | Confirmed no hot water on Memory Care Unit |
| Registered Nurse #316 | RN | Confirmed no hot water on Memory Care Unit and observed medication administration deficiency |
| Director of Nursing | DON | Verified concerns about linens, garbage bags, medication handling, and blood pressure monitoring |
| Laundry/Housekeeping Supervisor #506 | Laundry/Housekeeping Supervisor | Confirmed insufficient towels, washcloths, and garbage bags |
| Minimum Data Set Registered Nurse #260 | MDS RN | Confirmed lack of anticoagulant therapy care plans |
| Licensed Social Worker #254 | LSW | Confirmed care plan meetings are to be held quarterly and verified care conference scheduling |
| Assistant Director of Nursing #261 | ADON | Confirmed no physician notification for high blood pressure readings |
| Registered Nurse Coordinator #319 | RN Coordinator | Confirmed physician orders were not followed and no notification for high blood pressure |
| Physician #500 | Physician | Confirmed expectation to be notified of high blood pressure readings and orthostatic BP orders |
| Certified Nursing Assistant #353 | CNA | Confirmed meals were late on Memory Care Unit |
| Dietary Aide #270 | Dietary Aide | Confirmed lunch meal trays were late |
| Dietary Manager #200 | Dietary Manager | Confirmed lunch meal trays were late and staff were not timely serving trays |
| Dietary Supervisor #406 | Dietary Supervisor | Confirmed lunch meal trays were late and cause was occasional delays |
| Registered Nurse #316 | RN | Observed improper medication handling during administration |
| RN Nursing Coordinator #319 | RN Coordinator | Confirmed nurses should not touch pills with bare hands and should use gloves |
| Maintenance Tech #380 | Maintenance Technician | Explained boiler system issues and hot water availability problems |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 19
Date: Aug 4, 2025
Visit Reason
The inspection was conducted due to complaints and allegations regarding resident care, dignity, financial management, medication administration, staffing, and facility conditions.
Complaint Details
The complaint investigation included allegations of neglect, abuse, inadequate staffing, medication errors, financial mismanagement, and failure to provide adequate care and services to residents, including Resident #145 and others.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, inadequate access to resident funds, medication errors, failure to notify family and physicians timely, inadequate abuse investigation, incomplete assessments and care plans, insufficient assistance with activities of daily living, pressure ulcer care deficiencies, unsecured medications, inadequate staffing, poor food quality and temperature, improper diet texture preparation, ineffective administration and financial management, and unsanitary living conditions.
Deficiencies (19)
Failure to honor resident's right to a dignified existence, self-determination, communication, and to exercise rights.
Failure to ensure residents had access to funds in a reasonable amount of time.
Failure to honor Resident #145's power-of-attorney request to hold Depakote medication.
Failure to notify Resident #145's family and physician timely of changes in behavior and medications.
Failure to protect residents from abuse and neglect, including failure to meet financial obligations affecting care.
Failure to respond appropriately to alleged violations of abuse.
Failure to complete a thorough and adequate investigation of abuse allegations in a timely manner.
Failure to ensure an assessment was completed before Resident #145 was placed on the secure/memory care unit.
Failure to create and implement an individualized care plan to address Resident #145's behaviors.
Failure to provide dependent residents with two showers per week as scheduled.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in actual harm to Resident #95.
Failure to ensure medications were secure on the memory care unit.
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Failure to provide appropriate treatment and services to a resident who displays or is diagnosed with dementia, resulting in immediate jeopardy.
Failure to ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Failure to ensure residents received food prepared in a form designed to meet individual needs, including puree diet consistency.
Failure to administer the facility in a manner that enables it to use its resources effectively and efficiently, including financial solvency and management.
Failure to establish a governing body legally responsible for establishing and implementing policies for managing and operating the facility.
Failure to maintain a sanitary and homelike environment for residents, staff, and the public.
Report Facts
Facility census: 141
Residents affected: 42
Residents affected: 35
Residents affected: 8
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #714 | Certified Nursing Assistant | Named in unprofessional behavior and yelling at Resident #26's son |
| DON | Director of Nursing | Verified CNA #714's behavior and other findings |
| RN #688 | Registered Nurse | Nursing coordinator involved in investigation of CNA #714 |
| LPN #589 | Licensed Practical Nurse | Involved in medication administration issue for Resident #145 |
| LPN #721 | Licensed Practical Nurse | Verified communication issues regarding Depakote medication for Resident #145 |
| CNA #568 | Certified Nursing Assistant | Involved in abuse incident with Resident #145 |
| CNA #800 | Certified Nursing Assistant | Involved in abuse incident with Resident #145 |
| LPN #544 | Licensed Practical Nurse | Facility wound nurse involved in pressure ulcer care |
| RD #732 | Registered Dietitian | Involved in nutrition care and payment issues |
| RD #730 | Registered Dietitian | Involved in nutrition care and payment issues |
| Administrator | Facility Administrator | Named in financial and administrative deficiencies |
| Pastor #733 | Chaplain/Religious Director | Named in nonpayment for services |
| CFO #740 | Chief Financial Officer | Named in financial management issues |
| CEO #1010 | Chief Executive Officer | Named in financial management issues |
| LPN #648 | Licensed Practical Nurse | Reported staffing and care issues on memory care unit |
| RN #578 | Registered Nurse | Involved in incident response on memory care unit |
| LPN #712 | Licensed Practical Nurse | Involved in incident response on memory care unit |
| CNA #667 | Certified Nursing Assistant | Reported puree diet food issues |
| LPN #639 | Licensed Practical Nurse | Reported unsecured medication cart |
| Housekeeper #549 | Housekeeper | Reported lack of housekeeping staff |
| Maintenance #575 | Director of Maintenance | Reported landscaping issues |
| BOM #536 | Business Office Manager | Involved in resident funds and petty cash issues |
| Social Services #400 | Social Worker | Implemented notification protocol for Resident #145 |
| Social Services #502 | Social Worker | Implemented notification protocol for Resident #145 |
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 5
Date: May 12, 2025
Visit Reason
The inspection was conducted due to complaints and concerns regarding the facility's failure to pay bills, resulting in service interruptions and potential resident neglect, as well as issues related to care planning, bathing assistance, staffing information posting, and facility cleanliness.
Complaint Details
This complaint investigation was triggered by multiple complaints including Master Complaint Number OH00165316 and Complaint Numbers OH00165311, OH00165058, OH00165031, OH00163700, OH00165313, and OH00165031.
Findings
The facility failed to manage financial obligations leading to trash accumulation and service interruptions affecting all residents. Care plans for two residents were incomplete regarding behavioral and skin care needs. Two residents did not receive bathing assistance as scheduled. Staffing information was not posted timely. The facility had ongoing ceiling leaks causing unsanitary conditions affecting the memory care unit.
Deficiencies (5)
Failure to effectively manage financial obligations resulting in trash accumulation and service interruptions.
Failure to develop and implement comprehensive care plans for Residents #102 and #122.
Failure to provide scheduled bathing assistance to Residents #67 and #102.
Failure to post nurse staffing information daily and timely.
Failure to maintain a clean and sanitary environment due to ceiling leaks and water damage in the memory care unit.
Report Facts
Residents affected: 132
Outstanding balance: 26972.36
Outstanding balance: 175167.84
Outstanding balance: 42921.74
Outstanding balance: 1513.7
Outstanding balance: 3086.32
Outstanding balance: 1400
Outstanding balance: 3360.21
Outstanding balance: 635.35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #302 | Certified Nursing Assistant | Reported concerns about trash accumulation, unpaid bills, and potential resident neglect. |
| Maintenance #404 | Maintenance Staff | Reported trash accumulation and ceiling leaks; moved trash after Fire Marshall's directive. |
| Administrator | Interviewed multiple times regarding financial issues, service interruptions, and vendor payments. | |
| LPN #336 | Licensed Practical Nurse | Responsible for care plans; confirmed lack of behavioral care plan for Resident #122. |
| LPN #320 | Licensed Practical Nurse | Confirmed behavioral issues for Resident #122 and lack of care planned interventions. |
| CNA #412 | Certified Nurse Aide | Reported difficulty managing Resident #122's behaviors and lack of specific interventions. |
| LPN #303 | Licensed Practical Nurse | Confirmed lack of care plan for Resident #102's pressure ulcers and related interventions. |
| ADON #410 | Assistant Director of Nursing | Confirmed missing shower documentation for Residents #67 and #102. |
| CNA #352 | Certified Nurse Aide | Confirmed bathing schedules and documentation procedures. |
| CNA #513 | Certified Nurse Aide | Confirmed bathing schedules and lack of bathing documentation for Resident #67 and #102. |
| CNA #514 | Certified Nurse Aide | Confirmed bathing schedules and documentation requirements. |
| CNA #313 | Certified Nurse Aide | Confirmed shower books and documentation of bathing and refusals. |
| Housekeeping and Laundry Supervisor #451 | Confirmed ceiling leaks and potential contamination of laundry. | |
| Director of Nursing | Director of Nursing | Confirmed staffing information posting delay. |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 1
Date: Mar 10, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to transfer residents appropriately using a mechanical lift, which resulted in a fall.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00163479.
Findings
The facility failed to transfer Resident #19 using a hoyer lift as ordered, resulting in a fall without injury. The fall occurred when two staff members transferred the resident without the mechanical lift, confirmed by medical record review and staff interview.
Deficiencies (1)
Failure to transfer residents appropriately using a mechanical lift resulting in a fall.
Report Facts
Facility census: 145
Residents reviewed for falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 03/10/25 verifying staff did not use hoyer lift |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 6
Date: Jan 30, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to notify resident representatives of significant weight loss, inadequate personal hygiene care, failure to complete showers as scheduled, pressure ulcer care deficiencies, incomplete fall risk assessments, improper antibiotic use monitoring, and lack of COVID-19 vaccine education.
Complaint Details
The deficiencies were investigated under Complaint Number OH00139109.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of significant weight loss, inadequate nail care and shower assistance for dependent residents, failure to timely identify and treat pressure ulcers, incomplete fall risk assessments for residents, lack of antibiotic use assessments prior to medication initiation, and failure to provide COVID-19 vaccine education to residents.
Deficiencies (6)
Failed to ensure resident representatives were notified of significant weight loss for Resident #70.
Failed to ensure fingernails were cleaned and trimmed for dependent residents and showers were completed as scheduled for certain residents.
Failed to timely identify areas of new skin impairment and provide appropriate pressure ulcer care for Resident #39.
Failed to ensure fall risk assessments were completed timely for Residents #29 and #34.
Failed to ensure antibiotic assessments were completed prior to initiation of antibiotic medication for Resident #56.
Failed to provide COVID-19 vaccine education and obtain declination forms for Residents #44 and #51.
Report Facts
Facility census: 108
Weight loss: 14.2
Weight loss percentage: 11.5
Weight loss: 16
Weight loss percentage: 12.9
Dates of missed showers: 2
Dates of missed showers: 1
Pressure ulcer size: 2.5
Pressure ulcer size: 4.7
Protein level: 6.9
Albumin level: 3.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietician #172 | Registered Dietician | Verified no documentation of Resident #70's responsible party notification of significant weight loss. |
| State Tested Nursing Assistant #183 | STNA | Provided information about nail care and shower schedules. |
| Registered Nurse #72 | RN | Verified residents' fingernails were to be trimmed on shower days and confirmed observations of long fingernails. |
| Director of Nursing | DON | Confirmed lack of documentation for missed showers and refusals for Residents #41 and #45, and fall risk assessments for Resident #29 and #34. |
| Registered Nurse #18 | RN | Provided information about Resident #39's pressure ulcer care and history. |
| Registered Nurse #15 | RN | Verified lack of antibiotic assessments for Resident #56 and lack of COVID-19 vaccine education for Residents #44 and #51. |
Inspection Report
Annual Inspection
Census: 136
Deficiencies: 11
Date: Feb 6, 2020
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements and evaluate resident care and safety.
Findings
The facility was found deficient in multiple areas including inaccurate advanced directives documentation, failure to assess restraint use, improper PASARR screening, failure to apply adaptive equipment as ordered, unsafe resident transfers, lack of catheter care orders, incomplete staff performance evaluations, unnecessary psychotropic medication use, improper medication storage and disposal, inadequate food quality and temperature control, and lapses in infection prevention and control practices.
Deficiencies (11)
Failed to ensure Advanced Directives were clear and accurate for Resident #32.
Failed to assess use of Broda chair as a possible restraint for Resident #59.
Failed to accurately complete PASARR screening for Resident #46.
Failed to ensure Resident #32 had geri-sleeves applied per physician order.
Failed to conduct a safe Hoyer lift transfer for Resident #48.
Failed to ensure Resident #137 had orders for routine care and cleaning of indwelling urinary catheter.
Failed to complete annual performance evaluations for three STNAs.
Failed to ensure two residents were free from unnecessary psychotropic medications.
Failed to properly store medications and dispose of contaminated medications in medication carts.
Failed to ensure food was palatable, appropriately served, and at safe temperatures.
Failed to follow proper infection control measures during incontinence care for Resident #37 and dressing care for Resident #95.
Report Facts
Residents affected: 136
PRN Ativan doses: 6
Medication carts residents served: 37
Residents on dementia unit: 37
Mobile cognitively impaired residents: 10
Residents affected by food issues: 84
Residents receiving regular texture chicken: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #15 | Registered Nurse | Verified correct advanced directive order for Resident #32 |
| Registered Nurse #40 | Registered Nurse | Verified no restraint assessment for Resident #59 and no catheter care orders for Resident #137 |
| Registered Nurse #309 | Registered Nurse | Confirmed Resident #32 did not have geri-sleeves applied |
| Licensed Practical Nurse #77 | Licensed Practical Nurse | Observed unsafe Hoyer lift transfer for Resident #48 |
| Human Resource Manager #320 | Human Resource Manager | Confirmed missing annual performance evaluations for STNAs |
| Director of Nursing | Director of Nursing | Confirmed absence of physician responses to GDRs and inappropriate PRN medication use |
| Licensed Practical Nurse #139 | Licensed Practical Nurse | Observed loose medications in medication cart and improper disposal |
| Licensed Practical Nurse #183 | Licensed Practical Nurse | Observed loose medications in medication cart and confirmed cleaning procedures |
| Dietary Aid #265 | Dietary Aid | Observed using incorrect scoops and plating food |
| Dietary Manager #315 | Dietary Manager | Confirmed food temperature and palatability issues |
| Licensed Practical Nurse #316 | Licensed Practical Nurse | Observed soiled dressing left on floor in Resident #95's room |
| State Tested Nursing Assistant #158 | State Tested Nursing Assistant | Used improper technique during incontinence care for Resident #37 |
Inspection Report
Complaint Investigation
Census: 157
Deficiencies: 13
Date: Jan 16, 2019
Visit Reason
The inspection was conducted based on complaints and self-reported incidents regarding resident care, medication management, infection control, and dining services at Saint Luke Lutheran Home.
Complaint Details
The complaint investigation substantiated issues related to infection control tracking and monitoring for residents with symptoms of illness, including gastrointestinal symptoms, and failure to track ill staff.
Findings
The facility failed to provide dignified dining experiences, thorough investigations of abuse allegations, adequate personal care, timely wound care, safe use of mechanical lifts, proper catheter orders, pain management, medication administration accuracy, dental care, food safety, and infection control tracking. Multiple residents were affected by these deficiencies.
Deficiencies (13)
Failed to provide a dignified dining experience, causing residents to wait long periods without meals and inconsistent meal service at tables.
Failed to ensure thorough investigations of alleged verbal and physical abuse, lacking resident interviews and assessments.
Failed to ensure nail care was completed for a resident unable to perform self-care.
Failed to ensure timely wound care and skin checks, missing a wound on a resident's lower leg.
Failed to adjust treatment for a pressure ulcer that worsened from Stage I to Stage III, resulting in harm.
Failed to follow proper procedures with a mechanical lift causing a resident fall and failed to ensure two staff present during incontinence care resulting in another fall.
Failed to ensure physician orders for an indwelling urinary catheter for a resident.
Failed to provide pain medication prior to wound treatment and failed to adequately manage dental pain complaints.
Failed to ensure justification for continuing as needed antipsychotic medication beyond 14 days and failed to attempt non-pharmacological interventions before administering anti-anxiety medication.
Medication administration errors occurred due to failure to prime insulin pen needles before dosing, resulting in an 8.57% error rate.
Failed to obtain prompt dental services to treat a resident's complaints of dental pain.
Failed to ensure foods were served at safe and appetizing temperatures, with hot foods below 140°F and cold foods above 41°F, risking foodborne illness.
Failed to ensure effective infection control tracking and monitoring for residents with symptoms of illness, including gastrointestinal symptoms, and failed to track ill staff.
Report Facts
Residents affected by dining deficiency: 23
Residents affected by infection control deficiency: 59
Medication error rate: 8.57
Medication error opportunities: 35
Medication errors observed: 3
Residents in Twin Hills dining room: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #700 | Registered Nurse, Unit Supervisor | Unaware resident had not received lunch meal. |
| STNA #890 | State Tested Nurse Aide | Noted resident had not received lunch meal and delivered tray. |
| DDS #69 | Director of Dining Services | Observed meal service and commented on serving practices and food temperatures. |
| RN #896 | Unit Nurse | Confirmed nail care deficiency and pain medication timing. |
| LPN #1102 | Licensed Practical Nurse | Missed wound on resident's lower leg during skin check. |
| RN #68 | Registered Nurse | Verified pressure ulcer was acquired in house and confirmed medication error and pain management issues. |
| RN #903 | Registered Nurse | Observed dressing change on pressure ulcer. |
| STNA #1038 | State Tested Nurse Aide | Involved in mechanical lift fall incident. |
| STNA #1086 | State Tested Nurse Aide | Involved in mechanical lift fall incident. |
| RN #701 | Registered Nurse | Confirmed no physician orders for urinary catheter and pain medication timing. |
| RN #808 | Registered Nurse | Medication administration errors with insulin pens. |
| DON | Director of Nursing | Unaware of dental pain complaint and confirmed medication use issues. |
| ADON #819 | Assistant Director of Nursing | Confirmed infection control tracking deficiencies. |
| Physician #820 | Physician | Provided standing orders for residents with gastrointestinal symptoms. |
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