Inspection Reports for St. Margaret’s Family of Care
3525 Bienville St, New Orleans, LA 70119, United States, LA, 70119
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
17.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
333% worse than Louisiana average
Louisiana average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 9
Aug 20, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, safety, food handling, confidentiality, and pest control at St. Margaret's Daughters Home.
Findings
The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, failure to notify the state's LTC Ombudsman of resident discharge, incomplete PASRR Level II screening, inadequate care plan revisions and implementation after falls, unsecured hazardous chemicals, unlocked medication storage room, unsanitary food storage and handling practices, failure to maintain confidentiality of resident medical records, and presence of pests in the kitchen.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure a resident was assessed to safely self-administer medication prior to self-administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify the state's LTC Ombudsman in writing of a resident discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a Level II PASRR screening was completed for a resident admitted with a mental health disorder. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise and implement a resident's care plan after a witnessed fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure hazardous chemicals were secured and not accessible to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication storage room was locked and not accessible to residents or unauthorized staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain the facility's ice machine in a sanitary manner and failed to properly label and date food items; dietary staff failed to wear proper hair restraints. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to safeguard resident-identifiable information and maintain medical records confidentially. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a pest control program to prevent and deal with insects in the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents investigated for accidents: 4
Residents affected by hazardous chemicals accessibility: 5
Residents affected by confidentiality breach: 6
Black flying insects observed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Confirmed medication storage room should not be left unlocked; confirmed failures in care plan revisions and implementation; acknowledged unsanitary ice machine and pest issues. |
| S1 Administrator | Administrator | Acknowledged unsanitary ice machine, pest issues, and dietary hair restraint violations. |
| S8 Licensed Practical Nurse | Licensed Practical Nurse | Indicated resident #47 should not have had medication at bedside and was not assessed for self-administration. |
| S9 Social Services | Social Services | Unaware of requirement to notify LTC Ombudsman of resident discharge. |
| S13 Minimum Data Set Nurse | MDS Nurse | Indicated care plan was not updated after resident #72's fall. |
| S14 Certified Nursing Assistant | Certified Nursing Assistant | Attempted to transfer resident #72 without assistance, violating care plan. |
| S11 Dietary Manager | Dietary Manager | Confirmed unsanitary ice machine and failure to wear hair restraints. |
| S10 Dietary Aide | Dietary Aide | Observed assembling food without hair restraint. |
| S3 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed medication storage room was left unlocked; observed confidential records improperly stored. |
| S4 Assistant Director of Nursing | Assistant Director of Nursing | Confirmed confidential records improperly stored in common area. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Aug 20, 2025
Visit Reason
The inspection was conducted to investigate complaints related to medication self-administration, care plan revisions after falls, accident hazards including unsecured chemicals, supervision to prevent falls, pest control issues, and overall resident safety.
Findings
The facility failed to ensure a resident was properly assessed before self-administering medication, failed to update and implement care plans after a witnessed fall, allowed hazardous chemicals to be accessible to residents, did not provide adequate supervision to prevent falls, and failed to maintain a pest-free environment in the kitchen.
Complaint Details
The investigation was complaint-driven, focusing on medication self-administration safety, care plan adequacy after falls, accident hazards including chemical accessibility, supervision failures leading to falls, and pest control issues. The complaints were substantiated with findings of minimal harm or potential for harm.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure a resident was assessed to safely self-administer medication prior to self-administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise and implement a resident's care plan after a witnessed fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nursing home area was free from accident hazards and provided adequate supervision to prevent accidents, including unsecured hazardous chemicals accessible to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure sufficient supervision to prevent a resident fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the facility was free of pests, with black flying insects observed in the kitchen and dry storage room. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents investigated for accidents: 4
Residents affected by chemical hazard: 5
Black flying insects observed: 4
Black flying insects observed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S2 Director of Nursing | Director of Nursing | Indicated Resident #47 should not have had medication at bedside and Resident #72's care plan was not updated or implemented after fall |
| S8 Licensed Practical Nurse | Licensed Practical Nurse | Indicated Resident #47 should not have access to Voltaren gel and was not assessed for self-administration |
| S14 Certified Nursing Assistant | Certified Nursing Assistant | Attempted to transfer Resident #72 without assistance, resulting in a fall |
| S11 Dietary Manager | Dietary Manager | Confirmed presence of black flying insects in kitchen and dry storage room |
| S1 Administrator | Administrator | Acknowledged black flying insects should not be present and that S11DM should have notified pest control and administration |
Inspection Report
Complaint Investigation
Deficiencies: 6
Dec 18, 2024
Visit Reason
The inspection was conducted based on complaints and observations related to pressure ulcer care, medication errors, medication administration documentation, staffing data submission, infection control practices, and laundry handling.
Findings
The facility was found deficient in multiple areas including failure to perform weekly skin assessments as ordered, medication errors exceeding 5%, inaccurate medication administration documentation, failure to submit required staffing data, inadequate hand hygiene by CNAs during incontinence care, and improper handling and separation of clean and dirty laundry.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to perform ordered skin assessments, medication errors, inaccurate medication documentation, failure to submit staffing data, and infection control breaches.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to follow a physician's order to perform a weekly skin assessment for a resident at risk for pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate was 6.66%, exceeding the 5% threshold, involving incorrect medication and dosage administration to residents. | Level of Harm - Minimal harm or potential for actual harm |
| Medication administration record was inaccurately documented for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to electronically submit complete and accurate direct care staffing information as required. | Level of Harm - Minimal harm or potential for actual harm |
| Certified Nursing Assistants did not perform hand hygiene during incontinence care for observed residents. | Level of Harm - Minimal harm or potential for actual harm |
| Clean laundry was not kept separate from dirty and/or contaminated laundry in one of the laundry rooms observed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 6.66
Residents observed for medication errors: 7
Residents affected by medication errors: 2
Dates medication administered (Resident #R5): 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S15 Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Confirmed Resident #2's skin assessment was not completed as ordered. |
| S2 Director of Nursing | Director of Nursing (DON) | Confirmed deficiencies related to skin assessment, medication errors, inaccurate medication documentation, hand hygiene, and medication administration. |
| S7 Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Attempted to administer incorrect medication and dosage to Resident #3 and Resident #R5. |
| S16 Pharmacist | Pharmacist | Indicated Ferrous Sulfate should not be used in place of Ferrous Gluconate unless approved by a physician. |
| S8 Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Documented inaccurate medication administration for Resident #R5 and administered incorrect dosage. |
| S14 Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Documented medication administration for Resident #R5 on 12/10/2024. |
| S12 Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Did not perform hand hygiene or change gloves during incontinence care for Resident #R6. |
| S13 Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Did not perform hand hygiene before and after peri-care for Resident #R7. |
| S5 Housekeeper | Housekeeper | Indicated clean and dirty laundry were mixed and unlabeled in laundry room. |
| S10 Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Indicated laundry baskets were unlabeled and mixed clean and dirty laundry. |
| S11 Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Indicated dirty linen was improperly placed in handwashing sink. |
| S4 Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Indicated dirty linen should not be placed in handwashing sink. |
| S1 Administrator | Administrator | Confirmed CNA staff collected, washed, and dried resident clothing in facility laundry area. |
Inspection Report
Routine
Deficiencies: 8
Aug 28, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, staff performance, infection control, food safety, and vaccination policies at St. Margaret's Daughters Home.
Findings
The facility was found deficient in maintaining a clean and safe environment, accurate and complete physician progress notes, staff performance reviews and in-service training, food safety and sanitation, infection prevention and control programs, vaccination documentation, and water management. Several residents' rooms and equipment were unclean or in disrepair, expired food was found in the kitchen, temperature checks were not documented, and infection tracking was inadequate.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure residents' rooms and equipment were kept clean and in good repair for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician progress notes were complete and accurate; notes were photocopied with dates changed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Certified Nursing Assistant had a performance review within the last 12 months. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was procured, stored, prepared, and served in accordance with professional standards, including presence of expired food and unsanitary kitchen conditions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff checked and documented temperatures of steam tables and refrigerator/freezers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain documented evidence of water management program for legionella and accurate tracking and trending of facility infections. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident medical records contained documentation of education and refusal of influenza and pneumococcal vaccinations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Certified Nursing Assistants received 12 hours of in-service training annually. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for environment: 7
Residents with unclean rooms/equipment: 2
Residents with equipment in disrepair: 3
Residents reviewed for physician progress notes: 2
Certified Nursing Assistants reviewed for performance review: 3
Expired food items observed: 5
Infections logged in May 2024: 3
Infections logged in June 2024: 7
Infections logged in July 2024: 7
Residents reviewed for immunizations: 5
Residents with vaccination documentation issues: 4
Certified Nursing Assistants reviewed for in-service training: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S14 Nurse Practitioner | Nurse Practitioner | Named in inaccurate physician progress notes finding |
| S1 Administrator | Administrator | Confirmed policy violations regarding physician notes and food safety |
| S2 Director of Nursing | Director of Nursing | Commented on physician notes and infection control deficiencies |
| S3 Chief Operating Officer | Chief Operating Officer | Confirmed lack of CNA performance reviews and in-service training documentation |
| S4 Quality Director | Quality Director | Discussed infection control and vaccination documentation deficiencies |
| S5 CNA | Certified Nursing Assistant | Lacked performance review and in-service training documentation |
| S6 CNA | Certified Nursing Assistant | Lacked in-service training documentation |
| S7 CNA | Certified Nursing Assistant | Lacked in-service training documentation |
| S9 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed unclean conditions in Resident #36's room |
| S12 Dietary Manager | Dietary Manager | Acknowledged expired food and unsanitary kitchen conditions |
| S15 Homemaker | Homemaker | Failed to check food temperatures on steam table and refrigerator/freezer |
| S16 Homemaker | Homemaker | Failed to check food temperatures on steam table and refrigerator/freezer |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 27, 2024
Visit Reason
The inspection was conducted due to complaints of psychosocial abuse by a Certified Nursing Assistant (S5CNA) towards three residents (Resident #1, Resident #2, Resident #3).
Findings
The facility failed to protect residents from psychosocial abuse by S5CNA, who was rude, disregarded residents' requests, and caused emotional distress. The abuse was substantiated, and the CNA was terminated immediately following the investigation.
Complaint Details
The complaint was substantiated based on interviews and record reviews indicating psychosocial abuse by S5CNA towards three residents. The abuse included verbal disparagement, rough handling, and disregard of residents' requests. The CNA was terminated as a result.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to protect residents from psychosocial abuse by S5CNA, including verbal abuse and rough handling. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
BIMS scores: 13
BIMS scores: 11
BIMS scores: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S5 CNA | Certified Nursing Assistant | Named as the staff member responsible for psychosocial abuse towards residents. |
| S1 Administrator | Administrator | Conducted interviews following abuse reports and terminated S5 CNA. |
| S2 CNA | Certified Nursing Assistant | Reported residents' complaints and observed Resident #1 upset. |
| S3 LPN | Licensed Practical Nurse | Reported observations and residents' complaints about S5 CNA's behavior. |
| S4 LPN | Licensed Practical Nurse | Reported S5 CNA's rude behavior and observed Resident #1 crying. |
Inspection Report
Routine
Deficiencies: 11
Oct 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, notification procedures, assessments, nursing aide training, staffing, infection control, and food safety at St. Margaret's Daughters Home.
Findings
The facility was found deficient in multiple areas including failure to respect resident rights, timely issuance of Medicare non-coverage notices, completion of significant change assessments, PASARR Level II evaluations, comprehensive care planning, provision of nail care, application of physician-ordered treatments, CNA registry verification, posting of nurse staffing information, proper food labeling and storage, and infection control practices related to ice supply and whirlpool sanitation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to respect a resident's right to have her fingernails untrimmed as requested. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to issue Notice of Medicare Non-Coverage in a timely manner for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete a Significant Change in Status Minimum Data Set within 14 days of hospice admission. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident with mental health diagnosis was referred for a PASARR Level II evaluation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive care plans addressing ADLs, medication self-administration, and mental health diagnoses for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide nail care for a dependent resident requiring assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure compression stockings and splint were applied per physician orders for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to verify CNA state registry prior to hire for three CNAs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post nurse staffing information daily as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly label leftover food and store food off the freezer floor in kitchen areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain ice scoop containment and ensure proper whirlpool disinfection procedures. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care planning: 21
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 2
CNAs without registry verification: 3
Residents affected: 1
CNAs interviewed for infection control: 4
CNAs with deficient whirlpool sanitation knowledge: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S24 Registered Nurse | Registered Nurse | Named in fingernail cutting deficiency |
| S1 Administrator | Administrator | Acknowledged fingernail cutting error and CNA registry check deficiency |
| S25 Social Worker | Social Worker | Responsible for issuing NOMNC and PASARR Level II evaluation referral |
| S2 Director of Nursing | Director of Nursing | Confirmed PASARR Level II screening deficiency and care plan issues |
| S5 Minimum Data Set Nurse | MDS Nurse | Confirmed care plan deficiencies related to medication self-administration and mental health |
| S28 Licensed Practical Nurse | Licensed Practical Nurse | Received verbal order for medication self-administration but did not update orders |
| S26 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed splint order for Resident #40 |
| S24 Registered Nurse | Registered Nurse | Confirmed splint order for Resident #40 |
| S3 Chief Operating Officer | Chief Operating Officer | Confirmed splint application deficiency and whirlpool disinfection issues |
| S8 Dietary Manager | Dietary Manager | Acknowledged food labeling and storage deficiencies |
| S19 Certified Nursing Assistant | Certified Nursing Assistant | Interviewed about whirlpool sanitation practices |
| S20 Certified Nursing Assistant | Certified Nursing Assistant | Interviewed about whirlpool sanitation practices |
| S23 Certified Nursing Assistant | Certified Nursing Assistant | Interviewed about whirlpool sanitation practices |
| S4 Chief Clinical Officer | Chief Clinical Officer | Stated proper disinfectant dwell time for whirlpool |
Inspection Report
Complaint Investigation
Deficiencies: 7
Oct 12, 2023
Visit Reason
The inspection was conducted to investigate complaints related to resident rights, notification of Medicare non-coverage, provision of care including nail care, application of compression stockings and splints, nurse aide registry verification, and nurse staffing postings.
Findings
The facility was found to have multiple deficiencies including failure to respect a resident's right to refuse nail trimming, failure to issue timely Notice of Medicare Non-Coverage, inadequate nail care for a dependent resident, failure to apply compression stockings and splints per physician orders, incomplete CNA registry verifications prior to hire, and failure to post nurse staffing information daily.
Complaint Details
The visit was complaint-related addressing issues such as resident rights violations, failure to provide timely Medicare non-coverage notices, inadequate personal care, failure to follow physician orders, incomplete staff registry checks, and failure to post staffing information.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to respect a resident's right to have her fingernails untrimmed despite her expressed wishes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to issue Notice of Medicare Non-Coverage (NOMNC) in a timely manner for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide nail care for a dependent resident who required assistance with nail cleanliness. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure compression stockings were applied per physician orders for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a splint was applied per physician orders for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete State Registry verifications prior to hire for three Certified Nursing Assistants. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post required nurse staffing information daily including resident census and staff hours. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for Activities of Daily Living (ADL): 4
Residents reviewed for beneficiary notification: 3
Residents affected by failure to issue NOMNC timely: 2
Certified Nursing Assistants personnel files reviewed: 8
Certified Nursing Assistants without registry verification: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S24 Registered Nurse | Registered Nurse | Named in nail trimming violation for Resident #88 |
| S1 Administrator | Administrator | Acknowledged nail trimming violation and CNA registry check deficiencies |
| S25 Social Worker | Social Worker | Responsible for issuing NOMNCs; confirmed failure to issue timely notices |
| S29 Certified Nursing Assistant | Certified Nursing Assistant | Interviewed regarding nail care for Resident #62 |
| S30 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed presence of dark brown substance under Resident #62's nails |
| S11 Licensed Practical Nurse | Licensed Practical Nurse | Acknowledged Resident #32 did not have compression stockings applied |
| S2 Director of Nursing | Director of Nursing | Confirmed Resident #32 should have compression stockings applied |
| S26 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed order to apply splint to Resident #40's left hand |
| S24 Registered Nurse | Registered Nurse | Confirmed Resident #40 had a splint order and it should be applied daily |
| S3 Chief Operating Officer | Chief Operating Officer | Stated Resident #40 should have splint applied per physician orders |
Inspection Report
Complaint Investigation
Deficiencies: 5
Apr 18, 2023
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident care, grievance handling, incontinence care, and infection control practices at St. Margaret's Daughters Home.
Findings
The facility failed to provide privacy during incontinence care, did not document or investigate resident grievances properly, failed to provide timely incontinence care to dependent residents, lacked annual CNA competency documentation, and breached infection control protocols including improper glove use and handling of soiled items.
Complaint Details
The visit was complaint-related due to allegations of inadequate privacy during care, failure to document and resolve grievances, delayed incontinence care, lack of staff competency documentation, and breaches in infection control practices. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide privacy for a resident during incontinence care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document resident grievances and investigations properly. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide timely incontinence care to dependent residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure CNAs completed annual competencies as required. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper infection control practices including glove use and handling of soiled items during incontinence care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 4
CNAs missing competencies: 2
Staff observed with infection control breaches: 3
Residents sampled for incontinence care: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Acknowledged privacy and grievance documentation issues; stated policies on privacy and grievance handling. |
| S2 Director of Nursing | Director of Nursing (DON) | Acknowledged ongoing issues with ADL care, grievance documentation, and infection control breaches. |
| S3 Social Worker | Social Worker | Responsible for grievance documentation; admitted lack of documentation and investigation of grievances. |
| S4 Office Manager/Certified Nursing Assistant | Office Manager/CNA | Observed providing incontinence care with infection control breaches; lacked annual competency documentation. |
| S6 Certified Nursing Assistant | Certified Nursing Assistant | Observed providing incontinence care with infection control breaches; lacked annual competency documentation. |
| S7 Certified Nursing Assistant | Certified Nursing Assistant | Observed providing incontinence care with infection control breaches and improper handling of soiled items. |
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