Inspection Reports for The Bristol at Tampa Rehabilitation & Nursing Center
1818 E Fletcher Ave, Tampa, FL 33612, FL, 33612
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 26, 2025, found multiple deficiencies related to resident dignity, communication, accommodation of needs, notification of condition changes, cleanliness, nutrition, infection control, documentation, and equipment maintenance. Earlier inspections showed a pattern of issues involving resident care, grievance handling, abuse investigations, medication administration, and safety practices, including a prior immediate jeopardy finding related to fire hazards and abuse in December 2023. Complaint investigations substantiated failures in timely resident assessments after falls, medication administration, and abuse reporting, with some staff terminations following abuse findings. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates ongoing challenges with resident care and safety, with no clear improvement trend evident over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
26.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
476% worse than Florida average
Florida average: 4.6 deficiencies/year
Deficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 9
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, communication, safety, nutrition, infection control, equipment maintenance, and overall facility conditions.
Findings
The facility was found deficient in maintaining resident dignity during care and meal assistance, providing language assistance to residents with limited English proficiency, accommodating resident needs such as call light accessibility and wheelchair provision, notifying physicians and families of changes in condition, maintaining a clean and safe environment, providing enteral nutrition as ordered, following infection control protocols, ensuring timely physician documentation, and maintaining safe patient care equipment including mechanical lifts.
Deficiencies (9)
Failed to ensure dignity was maintained for residents during care and meal assistance.
Failed to provide language assistance to a resident with limited English proficiency.
Failed to accommodate residents' needs related to call light accessibility and wheelchair provision.
Failed to notify physician and/or family of changes in condition and treatment for three residents.
Failed to maintain resident rooms, common areas, equipment and furnishings in a clean, safe and sanitary manner.
Failed to provide enteral nutrition according to physician orders for one resident.
Failed to ensure physician notes were available in a timely manner for four residents.
Failed to follow infection control standards related to hand sanitizing during medication administration and use of gloves when cleaning equipment.
Failed to ensure patient care equipment including mechanical lifts were maintained in a safe operating condition.
Report Facts
Residents sampled: 65
Residents sampled for dignity: 36
Residents affected by dignity deficiency: 3
Residents sampled for language assistance: 65
Residents affected by language assistance deficiency: 1
Residents sampled for call light and wheelchair needs: 65
Residents affected by call light and wheelchair deficiency: 5
Residents sampled for infection control: 65
Residents affected by infection control deficiency: 5
Weight loss percentage: 10.34
Tube feeding rate: 40
Tube feeding bottle hang time: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Named in infection control and medication administration findings |
| Staff G | Certified Nursing Assistant (CNA) | Named in dignity and meal assistance findings |
| Staff X | Licensed Practical Nurse (LPN)/Unit Manager | Named in wheelchair and tube feeding findings |
| Staff F | Licensed Practical Nurse (LPN) | Named in infection control and medication administration findings |
| Staff Y | Licensed Practical Nurse (LPN) | Named in tube feeding findings |
| Staff M | Risk Manager (RM)/Assistant Director of Nursing (ADON) | Named in mechanical lift incident investigation |
| Staff P | Certified Nursing Assistant (CNA) | Named in mechanical lift incident investigation |
| Staff T | Maintenance Assistant | Named in mechanical lift maintenance |
| Director of Nursing | Director of Nursing (DON) | Named in multiple findings and interviews |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Named in multiple findings and interviews |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 5, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to properly assess a resident immediately after a fall and failure to provide physician-ordered medication.
Complaint Details
The complaint investigation found substantiated issues related to failure to assess a resident immediately after a fall and failure to administer prescribed medication due to pharmacy prescription issues.
Findings
The facility failed to ensure that a resident who fell was assessed by a nurse before being moved by CNAs, and failed to provide prescribed medication (Pregabalin) due to lack of prescription transmission to the pharmacy. Interviews and record reviews confirmed these deficiencies.
Deficiencies (2)
Failure to ensure one resident was assessed immediately by a nurse after being found on the floor before being moved by CNAs.
Failure to provide physician ordered medication (Pregabalin) for one resident due to missing prescription at pharmacy and lack of medication availability.
Report Facts
Medication administration opportunities missed: 5
Date of fall incident: Resident #1 fell on 4/22/2025.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Authored nurse progress note and involved in assessment after resident fall. |
| Staff B | Certified Nursing Assistant (CNA) | Assisted resident to bathroom and involved in fall incident. |
| Staff C | Licensed Practical Nurse/Unit Manager (LPN UM) | Provided interview regarding fall protocol and medication administration. |
| Director of Nursing (DON) | Director of Nursing | Provided interview on fall protocol and medication administration policies. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 30, 2025
Visit Reason
The inspection was conducted based on complaints alleging failure to act upon a resident's grievances, failure to thoroughly investigate an abuse allegation, and failure to provide care and assistance with activities of daily living as per plan of care and resident choice.
Complaint Details
The complaint investigation included grievances about missing resident clothes not being addressed, an alleged staff slap incident that was not thoroughly investigated, and failure to provide bathing care as per resident preference and plan of care.
Findings
The facility failed to act on a resident's grievance regarding missing clothes, failed to conduct a thorough investigation of an alleged staff abuse incident, and failed to ensure two dependent residents received showers per their plan of care and preference. Documentation and interviews revealed lapses in grievance handling, abuse investigation procedures, and bathing care documentation and delivery.
Deficiencies (3)
Failed to act upon a resident's concerns and grievances regarding missing clothes.
Failed to ensure a thorough investigation was conducted for an allegation of staff slapping a resident.
Failed to ensure two dependent residents received showers per plan of care and choice.
Report Facts
Residents reviewed: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
BIMS score: 11
BIMS score: 15
BIMS score: 15
Shower documentation opportunities: 69
Dependent bathing documentation: 40
Substantial/maximum assistance: 14
Partial/moderate assistance: 2
No documentation: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Registered Nurse (RN) | Named in abuse allegation of slapping Resident #188 |
| Staff J | Assistant Administrator (AA) | Conducted interviews related to abuse allegation investigation |
| Social Services Director | Interviewed regarding grievance log and abuse investigation | |
| Director of Nursing | Interviewed regarding grievance initiation and bathing documentation | |
| Housekeeping and Laundry Supervisor | Interviewed regarding missing laundry grievance process | |
| Assistant Laundry Supervisor | Interviewed regarding missing laundry grievance process | |
| Staff K | Certified Nursing Assistant (CNA) | Interviewed regarding shower documentation and care |
| Staff Q | Certified Nursing Assistant (CNA) | Interviewed regarding shower documentation and care |
| Staff M | Certified Nursing Assistant (CNA) | Interviewed regarding shower documentation and care |
| Staff L | Certified Nursing Assistant (CNA) | Interviewed regarding shower documentation and care |
Inspection Report
Routine
Deficiencies: 9
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements including resident rights, assessments, PASRR screenings, care provision, and medication administration.
Findings
The facility was found deficient in multiple areas including failure to obtain consent for use of resident funds, late or incomplete assessments, failure to update PASRR screenings, inadequate provision of care including therapy and medication administration, improper use and documentation of orthotics, improper storage of urinary catheter bags, and lack of physician order for oxygen administration.
Deficiencies (9)
Failed to obtain consent prior to utilizing funds for one resident (#46).
Failed to assess a resident within the three months required for quarterly Minimum Data Set (MDS).
Failed to submit one resident (#188) for a Level II Pre-admission Screening and Resident Review (PASRR).
Failed to complete/update the Pre-admission Screening and Resident Reviews (PASRRs) for five residents (#228, #145, #163, #25, #60) with qualifying mental health diagnoses.
Failed to provide needed care and services for residents with immune deficiency syndrome, therapy services, and routine lab work.
Failed to screen one resident (#123) for orthotic use and failed to apply orthotics for two residents (#14 and #31).
Failed to ensure urinary drainage bags and tubing for two residents (#91 and #18) were stored in a manner to prevent infections.
Failed to ensure a physician order was available prior to providing oxygen administration for one resident (#150).
Failed to ensure the medication error rate was less than five percent; four medication errors were identified for two residents (#135 and #220).
Report Facts
Medication administration opportunities observed: 29
Medication errors identified: 4
Medication error rate: 13.79
CD4 count: 7
CD4 count: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) Minimum Data Set Coordinator | Interviewed regarding late quarterly MDS submission for Resident #196 |
| Staff B | Licensed Practical Nurse (LPN) Unit Manager East | Responsible for lab work results for Resident #200 |
| Staff C | Nurse Practitioner (NP) | Notified of Resident #200's abnormal lab work and discussed ART medication |
| Staff D | Registered Dietitian (RD) | Interviewed regarding diet order and therapy referral for Resident #170 |
| Staff E | Speech Language Pathologist (SLP) | Interviewed regarding speech therapy evaluations and referral for Resident #170 |
| Staff F | Licensed Practical Nurse (LPN) | Interviewed regarding orthotic use and medication administration errors |
| Staff G | Licensed Practical Nurse (LPN) | Observed administering medication with error for Resident #135 |
| Staff L | Certified Nursing Assistant (CNA) | Reported behavior of Resident #60 and assisted with catheter tubing |
| Staff N | Certified Nursing Assistant (CNA) | Observed Resident #14 and reported on orthotic use |
| Staff O | Registered Nurse (RN) | Observed Resident #91 and confirmed catheter tubing dragging on floor |
| Staff P | Rehab Tech | Documented orthotic application and discussed weekend splint application |
| Staff Q | Certified Nursing Assistant (CNA) | Observed Resident #31 and discussed orthotic application |
| Director of Nursing | Director of Nursing (DON) | Multiple interviews regarding lab work, oxygen orders, medication errors, and resident care |
| Director of Rehabilitation | Director of Rehabilitation (DoR) | Interviewed regarding orthotic use and therapy referrals |
| Social Service Director | Social Service Director (SSD) | Interviewed regarding PASRR screenings and appointment scheduling |
| Resident #200's Attending Physician | Attending Physician (AP) | Interviewed regarding Resident #200's immune deficiency syndrome care |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 1, 2023
Visit Reason
The inspection was conducted based on complaints and allegations regarding resident abuse, dignity violations, grievance handling, medication administration, and timely reporting of abuse incidents at The Bristol Care Center.
Complaint Details
The investigation was complaint-driven involving allegations of abuse, dignity violations, grievance mishandling, medication administration issues, and delayed reporting. Resident #30 alleged physical abuse by Staff S, CNA who restrained him causing bruising and skin tear. Resident #137 reported medication refusal issues with Staff V, RN, verbal conflicts, and police involvement. The facility failed to timely report these incidents as required.
Findings
The facility failed to ensure residents were treated with dignity and respect, failed to promptly resolve grievances, failed to protect residents from abuse including physical harm caused by staff restraint, failed to timely report allegations of abuse, and failed to maintain accurate medication administration records. Staff S, CNA was found to have abused Resident #30 causing bruising and a skin tear and was terminated. Resident #137 reported medication administration issues and verbal conflicts with Staff V, RN, with police involvement and delayed reporting. Documentation errors were found related to medication administration for Resident #137.
Deficiencies (5)
Failed to honor residents' rights to dignity and respect, including forcibly waking Resident #30 causing bruising.
Failed to promptly resolve grievance regarding missing personal briefs for Resident #137.
Failed to protect Resident #30 from physical abuse by Staff S, CNA who restrained resident causing bruising and skin tear.
Failed to timely report allegations of abuse and injuries of unknown source within required two-hour timeframe for Residents #30 and #137.
Failed to maintain accurate medication administration records for Resident #137, with medications administered by one nurse but documented by another.
Report Facts
Residents sampled: 58
Residents affected: 2
Deficiency counts: 5
BIMS score: 14
BIMS score: 15
Units of insulin administered: 2
Blood glucose level: 174
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Certified Nursing Assistant (CNA) | Named in abuse finding for restraining Resident #30 causing bruising and skin tear; terminated for substantiated abuse. |
| Staff V | Registered Nurse (RN) | Named in medication administration and verbal conflict complaints with Resident #137; suspended pending investigation. |
| Staff B | Licensed Practical Nurse (LPN) | Consistent nurse for Resident #203 and involved in medication administration documentation for Resident #137. |
| Staff J | Licensed Practical Nurse (LPN)/Unit Manager (UM) | Involved in handling Resident #203 name spelling issue and medication administration issues for Resident #137. |
| Staff G | Licensed Practical Nurse (LPN) | Observed administering insulin to Resident #137 but documentation was signed by another nurse. |
| Risk Manager | Provided statements regarding abuse reporting, investigation, and staff education. | |
| Administrator/Abuse Coordinator | Responsible for final decisions on abuse investigations; involved in reporting discrepancies and staff termination. |
Inspection Report
Immediate Jeopardy
Deficiencies: 14
Date: Dec 1, 2023
Visit Reason
The inspection was conducted due to multiple concerns including resident grievances not being followed up, unsafe and unsanitary environment conditions, failure to protect residents from abuse, failure to timely report abuse allegations, incomplete PASRR screenings, inadequate care planning, inaccurate code status documentation, unsafe smoking practices leading to fire hazards, failure to provide appropriate respiratory care, medication administration and infection control deficiencies.
Findings
The facility failed to follow up on resident grievances, maintain a safe and sanitary environment, protect residents from abuse, timely report abuse allegations, complete accurate PASRR screenings, develop and implement appropriate care plans, accurately document code status, ensure safe smoking practices, provide proper respiratory care, administer medications safely, and maintain infection control practices. These failures resulted in immediate jeopardy to resident health and safety, especially related to smoking safety and fire hazards affecting many residents.
Deficiencies (14)
Failure to follow up on resident grievances identified during Resident Council meetings.
Failure to maintain a safe, clean, comfortable, and homelike environment including rust on toilet and ceilings in disrepair.
Failure to ensure prompt effort to resolve a grievance related to missing personal belongings of a resident.
Failure to protect a resident from abuse resulting in bruising and skin tear due to improper restraint.
Failure to timely report allegations of abuse and injuries of unknown source within required two-hour timeframe.
Failure to complete PASRR Level II upon new qualifying mental health diagnosis and ensure accuracy of PASRR Level I for multiple residents.
Failure to develop and implement complete care plans that meet residents' needs including preferences and smoking interventions.
Failure to provide basic life support including accurate code status reflecting resident's advance directives.
Failure to ensure safe smoking practices and supervision, resulting in fire hazards and resident injuries.
Failure to provide and implement an infection prevention and control program related to medication administration, cleaning of glucose monitoring equipment, and hand hygiene before meals.
Failure to ensure medications were stored in a locked medication cart and not left at bedside.
Failure to ensure professional standards and practices were followed related to accurate documentation on a Medication Administration Record (MAR).
Failure to provide and implement an infection prevention and control program related to medication administration by staff and hand hygiene.
Failure to arrange for provision of hospice services or assist resident in transferring to a facility that will arrange for hospice services.
Report Facts
Residents who smoke: 44
Residents affected by smoking safety deficiencies: 14
Residents affected by medication monitoring deficiencies: 2
Residents affected by infection control deficiencies: 5
Residents affected by hand hygiene deficiencies: 13
Residents affected by hand hygiene deficiencies: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Certified Nursing Assistant | Named in abuse incident involving Resident #30 causing bruising and skin tear; terminated for substantiated abuse |
| Staff B | Licensed Practical Nurse | Documented medication administration for Resident #137 but did not administer; signed off on medications given by another nurse |
| Staff G | Licensed Practical Nurse | Performed glucose monitoring and administered insulin to Resident #137; did not perform hand hygiene; did not disinfect glucometer properly |
| Staff D | Licensed Practical Nurse | Observed leaving medication at bedside for Resident #103; did not perform hand hygiene |
| Staff E | Licensed Practical Nurse | Observed not disinfecting blood pressure cuff between uses |
| Staff H | Registered Nurse/Assistant Director of Nursing | Observed poor infection control practices during IV medication administration |
| Staff J | Licensed Practical Nurse/Unit Manager | Discussed medication administration and documentation issues for Resident #137 |
| Staff N | Licensed Practical Nurse | Reported on Resident #48's behavior and documentation practices |
| Staff O | Certified Nursing Assistant | Smoking aide; observed poor supervision and smoking safety practices |
| Staff K | Activities Director | Responsible for stocking cigarettes in smoking cart |
| Staff DD | Activities Assistant | Observed smoking supervision and apron use issues |
| Staff BB | Physician | Discussed Resident #61 smoking and oxygen use |
| Staff CC | Receptionist/Accounts Payable | Described resident sign-out and smoking area policies |
| Staff FF | Certified Nursing Assistant | Reported experience with smoking breaks and resident rapport |
| Staff W | Certified Nursing Assistant | Reported experience with smoking breaks and fires in building |
| Staff C | Assistant Director of Nursing/Infection Preventionist | Provided infection control education and policies; observed hand hygiene deficiencies |
| Staff I | Social Services Assistant | Discussed PASRR screening and advance directive processes |
| Staff L | Social Services Assistant | Discussed discharge planning and angel rounds |
| Staff JJ | Licensed Practical Nurse | Discussed Resident #219 code status and Resident #102 oxygen order clarification |
| Staff M | Certified Nursing Assistant | Reported on Resident #48 behavior and care refusals |
| Staff V | Registered Nurse | Involved in medication administration refusal incident with Resident #137 |
Inspection Report
Deficiencies: 1
Date: Jun 28, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with providing personal hygiene care, including shaving and nail care, to residents as per their choice and care plans.
Findings
The facility failed to ensure that two of six sampled residents (#20 and #24) received personal hygiene care, specifically shaving and nail care, according to their preferences and care plans over three days of observation. Resident #20 was found with unshaven facial hair and long, soiled fingernails before receiving care, and Resident #24 was observed with long, soiled fingernails and was dependent on staff for personal hygiene care without documentation of refusal.
Deficiencies (1)
Failure to provide personal hygiene care including shaving and nail care to residents #20 and #24 as per their choice and care plans during the observation period.
Report Facts
Residents reviewed for Activities of Daily Living: 6
Days observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #20's personal hygiene care and bathing schedule |
| Staff A | Floor Nurse | Interviewed about Resident #20's hygiene care and observations |
| Staff C | Certified Nursing Assistant (CNA) | Provided nail clipping and shaving care to Resident #20 on 6/26/2023 |
| Staff E | Certified Nursing Assistant (CNA) | Assisted Resident #24 with breakfast and confirmed nail care status |
| Staff F | Certified Nursing Assistant (CNA) | Observed Resident #24's fingernails on 6/28/2023 |
| Staff G | North East and North Unit Manager | Interviewed about nail care procedures and documentation |
Inspection Report
Routine
Deficiencies: 1
Date: Jun 28, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with providing personal hygiene care to residents, specifically focusing on activities of daily living such as shaving and nail care for residents who are unable to perform these tasks independently.
Findings
The facility failed to ensure that two of six sampled residents (#20 and #24) received personal hygiene care according to their preferences over three consecutive days. Observations and interviews revealed that Resident #20 was not shaved or provided nail care daily as he preferred, and Resident #24 had long, soiled fingernails with no documentation of refusal of care. The facility's policies on nail care were reviewed, and staff interviews indicated inconsistent documentation and care delivery.
Deficiencies (1)
Failure to provide personal hygiene care including shaving and nail care to residents #20 and #24 as per their choice over three days.
Report Facts
Residents reviewed for Activities of Daily Living: 6
Days observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) Staff B | Provided shaving and nail care to Resident #20 on 6/26/2023 | |
| Staff D | Certified Nursing Assistant (CNA) | Interviewed regarding Resident #20's care and bathing schedule |
| Staff A | North floor nurse | Interviewed about Resident #20's hygiene care and observations |
| Staff C | Certified Nursing Assistant (CNA) | Interviewed about Resident #20's hygiene care and observations |
| Staff E | Certified Nursing Assistant (CNA) | Assisted Resident #24 with breakfast and commented on nail care |
| Staff F | Certified Nursing Assistant (CNA) | Observed Resident #24's fingernails on 6/28/2023 |
| Staff G | North East and North Unit Manager | Interviewed about bathing, showering, and nail care policies and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: May 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an incident involving serious bodily harm to a resident and other related compliance issues.
Complaint Details
The complaint investigation focused on an incident where Resident #1 was found unresponsive and CPR was initially stopped due to a mistaken belief that the resident was DNR, when in fact the resident was a full code. The facility delayed reporting the incident due to survey activities. The investigation revealed communication barriers, improper chart handling, and failure to follow CPR protocols.
Findings
The facility failed to timely report an incident involving serious bodily harm to Resident #1, failed to ensure accurate assessments for residents, failed to provide basic life support according to advance directives, failed to properly manage diabetes care for several residents, failed to complete neurological checks after falls, failed to post updated nurse staffing information, failed to properly store medications, and failed to maintain accurate documentation. Immediate jeopardy related to failure to provide CPR according to code status was identified and later removed after corrective actions.
Deficiencies (9)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for one resident.
Failed to provide basic life support, including CPR, prior to the arrival of emergency medical personnel, subject to physician orders and the resident’s advance directives.
Failed to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically related to diabetes management.
Failed to ensure follow up neurological checks were completed after falls for nine residents.
Failed to post an updated daily nurse staffing data form for one day of five days observed.
Failed to ensure medications were stored properly in medication carts, treatment carts, and medication storage rooms.
Failed to maintain complete and accurate documentation for four residents.
Failed to ensure a functioning Quality Assurance Committee to review quality deficiencies and develop corrective plans of action.
Report Facts
Deficiencies cited: 9
Neuro checks required: 20
Neuro checks completed: 12
Neuro checks completed: 16
Neuro checks completed: 1
Neuro checks completed: 12
Blood glucose tests over 400: 11
Medication administration opportunities missed: 5
Medication carts with issues: 5
Medication storage rooms with issues: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Named in CPR incident involving Resident #1 and communication barrier. |
| Staff B | Registered Nurse (RN) | Supervisor involved in CPR incident and communication barrier with Staff A. |
| Staff C | Licensed Practical Nurse (LPN) | Pulled wrong chart leading to CPR error for Resident #1. |
| Staff V | Registered Nurse (RN) | Interviewed regarding MDS coding error for Resident #8. |
| Staff J | Licensed Practical Nurse (LPN) | Found Resident #2 after fall and documented progress note. |
| Staff H | Registered Nurse (RN)/UM | Signed off neuro checks not completed and reported pressure from supervisors. |
| Staff M | Licensed Practical Nurse (LPN) | Unit Manager who reported being asked to sign off documentation not done. |
| Staff D | Certified Nursing Assistant (CNA) | Assisted Staff A with translation and found Resident #1's chart. |
| Staff E | Certified Nursing Assistant (CNA) | Witnessed Resident #1 condition and assisted during CPR incident. |
| Staff N | Licensed Practical Nurse (LPN) | Reported medication administration issues for Resident #116. |
| Staff F | Licensed Practical Nurse (LPN)/Unit Manager | Observed cluttered medication refrigerator. |
| Staff I | Licensed Practical Nurse (LPN) | Observed unlabeled insulin vial and medication cart issues. |
| Staff K | Licensed Practical Nurse (LPN) | Removed loose pills from medication cart. |
| Staff L | Registered Nurse (RN) | Observed unlabeled opened medication bottles. |
| Staff M | Registered Nurse (RN) | Observed unlabeled opened medication bottles. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies and corrective actions. |
| Administrator | Nursing Home Administrator (NHA) | Interviewed regarding documentation and medication storage issues. |
| Regional Nurse Consultant | Regional Nurse Consultant (RNC) | Interviewed regarding diabetes medication administration and education. |
| Advanced Practice Registered Nurse | APRN | Conducted skin and wound evaluation for Resident #10. |
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