Deficiencies (last 3 years)
Deficiencies (over 3 years)
19.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
271% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Routine
Deficiencies: 4
Date: Mar 27, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to activities of daily living, range of motion, food preparation, and food safety in the nursing home.
Findings
The facility failed to ensure proper care for residents' activities of daily living, including nail care and contracture management for two residents, resulting in worsened contractures and potential skin breakdown. Additionally, the facility failed to prepare pureed food in the proper consistency for six residents and did not prevent cross-contamination during food service.
Deficiencies (4)
Failed to provide care and assistance for activities of daily living, including nail care, for 2 residents leading to contractures and skin breakdown.
Failed to provide appropriate care to maintain or improve range of motion for 2 residents, resulting in worsened contractures.
Failed to ensure food was prepared in the proper form for residents on pureed diets, with food containing chunks and watery consistency.
Failed to prevent cross-contamination during lunch service, including ungloved hands touching food and dishes, and improper handling of food items.
Report Facts
Residents affected: 2
Residents affected: 6
Date of survey completion: Mar 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Described Resident #9's left hand condition and care needs |
| CNA #8 | Certified Nursing Assistant | Described Resident #9's left hand condition and care needs |
| Administrator | Provided statements about nail care and contracture interventions | |
| Assistant Director of Nursing | ADON | Discussed hospice care plan and contracture care for Resident #9 |
| Rehab Director | RD | Discussed contracture care and system breakdown for Residents #9 and #49 |
| RNA #9 | Restorative Nurses Assistant | Observed and attempted care for Resident #49's contracted hand |
| RNA #10 | Restorative Nurses Assistant | Assisted in care for Resident #49's contracted hand |
| DC #2 | Dietary Cook | Observed preparing pureed food and described consistency issues |
| Dietary Manager | Discussed risks of improper food consistency and cross contamination | |
| DC #1 | Dietary Cook | Observed cross contamination during food service |
| DC #3 | Dietary Cook | Observed cross contamination during food service |
| CNA #4 | Certified Nursing Assistant | Observed pureed food consistency and described choking hazard |
| CNA #5 | Certified Nursing Assistant | Observed pureed food consistency and described choking hazard |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations related to activities of daily living, range of motion, food preparation, and safe food handling in the nursing home.
Findings
The facility failed to ensure proper care for residents' activities of daily living, including nail care and contracture management for two residents, resulting in worsened contractures and skin breakdown. Additionally, the facility failed to provide food in the proper pureed consistency for six residents and failed to prevent cross-contamination during food service.
Deficiencies (4)
Failed to ensure activities of daily living and nail care were performed for 2 residents, resulting in contractures with skin breakdown and poor hygiene.
Failed to provide appropriate care to maintain or improve range of motion for 2 residents, leading to worsened contractures.
Failed to ensure food was prepared in the proper pureed form, with chunks and watery consistency observed in pureed diets for six residents.
Failed to prevent cross-contamination during lunch service, including ungloved hand contact with food and dishes, risking resident safety.
Report Facts
Residents affected: 2
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Described Resident #9's left hand condition and care needs |
| CNA #8 | Certified Nursing Assistant | Described Resident #9's left hand condition and care needs |
| Administrator | Provided statements on nail care and contracture interventions | |
| Assistant Director of Nursing | ADON | Provided statements on hospice care plan and contracture management for Resident #9 |
| Rehab Director | RD | Discussed contracture care and system breakdown for Residents #9 and #49 |
| RNA #9 | Restorative Nurses Assistant | Observed cleaning and care attempts for Resident #49's contracted hand |
| RNA #10 | Restorative Nurses Assistant | Assisted in cleaning Resident #49's contracted hand |
| DC #2 | Dietary Cook | Observed preparing pureed food and described cross-contamination risks |
| DC #1 | Dietary Cook | Observed during food service with cross-contamination incidents |
| DC #3 | Dietary Cook | Observed during food service with cross-contamination incidents |
| Dietary Manager | Provided statements on food consistency and cross-contamination risks | |
| CNA #4 | Certified Nursing Assistant | Observed and commented on pureed food consistency |
| CNA #5 | Certified Nursing Assistant | Observed and commented on pureed food consistency |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 25, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations related to activities of daily living, range of motion, food preparation, and food safety in the facility.
Findings
The facility failed to ensure proper care for residents' activities of daily living, including nail care and contracture management for two residents, resulting in worsened contractures and potential skin breakdown. Additionally, the facility failed to prepare pureed food to the correct consistency for six residents and did not prevent cross-contamination during food service.
Deficiencies (4)
Failure to provide adequate care and assistance for activities of daily living, including nail care, for residents with contractures.
Failure to provide appropriate care to maintain or improve range of motion, resulting in worsened contractures for residents.
Failure to ensure food was prepared in the proper form for residents requiring pureed diets, with food containing chunks and watery consistency.
Failure to prevent cross-contamination during lunch service, including improper handling of food and utensils by dietary staff.
Report Facts
Residents affected: 2
Residents affected: 6
Dates of observations: Mar 24, 2025
Dates of observations: Mar 25, 2025
Dates of observations: Mar 26, 2025
Dates of observations: Mar 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Described Resident #9's left hand condition and care needs; notified surveyor of wound care order |
| CNA #8 | Certified Nursing Assistant | Described Resident #9's left hand condition and care needs; expressed concern about lack of interventions |
| Administrator | Stated nail care and contracture interventions should be done to prevent skin breakdown | |
| ADON | Assistant Director of Nursing | Discussed hospice care plan and pain management for Resident #9's contracture |
| RD | Rehab Director | Reported lack of contracture interventions and system breakdown for Residents #9 and #49 |
| RNA #9 | Restorative Nurses Assistant | Observed and attempted to clean Resident #49's contracted hand; described care process |
| RNA #10 | Restorative Nurses Assistant | Assisted in cleaning Resident #49's contracted hand; noted odor and condition |
| DC #2 | Dietary Cook | Observed preparing pureed food with improper consistency and involved in cross-contamination incidents |
| DC #1 | Dietary Cook | Observed handling food and utensils improperly leading to cross-contamination |
| DC #3 | Dietary Cook | Observed touching plates and involved in cross-contamination incidents |
| Dietary Manager | Discussed risks of improper food consistency and cross-contamination |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 25, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to activities of daily living, range of motion, food preparation, and safe food handling in the nursing home.
Findings
The facility failed to ensure proper care for residents' activities of daily living, including nail care and contracture management for two residents, resulting in worsened contractures and potential skin breakdown. Additionally, food served to residents on pureed diets was not prepared to the correct consistency, posing a choking hazard. Cross-contamination risks were observed during food service.
Deficiencies (4)
Failed to ensure activities of daily living and nail care were performed for 2 residents, resulting in contractures with embedded digits, food matter, odor, and skin breakdown risk.
Failed to provide appropriate care to maintain or improve range of motion for 2 residents, leading to worsened contractures and skin breakdown.
Failed to ensure food was prepared in the proper form for residents on pureed diets, with chunks and watery consistency posing choking hazards.
Failed to prevent cross contamination during lunch service, including ungloved hand contact with food and dishes, risking resident illness.
Report Facts
Residents affected: 2
Residents affected: 6
Scoops of chicken pot pie: 8
Scoops of broccoli and cauliflower: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #7 | Described Resident #9's left hand condition and care needs | |
| Certified Nursing Assistant (CNA) #8 | Described Resident #9's left hand condition and care needs | |
| Administrator | Provided statements on nail care and contracture interventions | |
| Assistant Director of Nursing (ADON) | Provided statements on hospice care plan and contracture management for Resident #9 | |
| Rehab Director (RD) | Discussed contracture conditions and care for Residents #9 and #49 | |
| Restorative Nurses Assistant (RNA) #9 and #10 | Observed providing care to Resident #49's contracted hand | |
| Dietary Manager | Discussed food consistency and risks of choking | |
| Dietary Clerks (DC) #1, #2, #3 | Observed during food preparation and service with cross contamination risks | |
| Certified Nursing Assistants (CNA) #4 and #5 | Observed during meal service and commented on food consistency |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 23, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to meal service and resident care.
Findings
The facility failed to serve a palatable meal at a safe and appetizing temperature for one resident out of three reviewed. Food temperatures were observed to be below acceptable ranges, and staff confirmed that food should have been warmed before serving.
Deficiencies (1)
Failed to serve a palatable meal for 1 of 3 residents reviewed for meal service, with food not served at appropriate temperatures.
Report Facts
Food temperature: 123
Food temperature: 123
Food temperature: 103.2
Food temperature: 83.1
Food temperature: 103.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Confirmed food should have been warmed for Resident #1 | |
| Dietary Manager | Obtained food temperatures and verbalized facility would make another plate due to improper temperatures |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 23, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulations related to meal service and food safety in the facility.
Findings
The facility failed to serve a palatable meal at a safe and appetizing temperature for one resident out of three reviewed. Food temperatures on the last tray served were below acceptable ranges, and staff confirmed meals should have been warmed before serving.
Deficiencies (1)
Failed to serve a palatable meal for Resident #1, with food served at improper temperatures.
Report Facts
Food temperature: 123
Food temperature: 123
Food temperature: 103.2
Food temperature: 83.1
Food temperature: 103.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Confirmed food should have been warmed before serving Resident #1 | |
| Dietary Manager | Obtained food temperatures and confirmed facility would remake plate due to improper temperatures |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 2, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety, storage, preparation, and serving standards in the nursing home kitchen and dining areas, focusing on meal temperature, food storage, sanitation, and hand hygiene practices.
Findings
The facility failed to ensure meals were served at acceptable temperatures, foods were properly stored, covered, sealed, and dated, and that kitchen and food preparation areas were maintained in sanitary conditions. Dietary staff also failed to consistently follow hand hygiene protocols. These deficiencies had the potential to cause minimal harm or potential for actual harm to residents.
Deficiencies (4)
Meals were served at temperatures below acceptable levels, with unheated food carts delivering trays at temperatures ranging from 90.8 to 115 degrees Fahrenheit.
Foods stored in dry storage, refrigerator, and freezer were uncovered, unsealed, and undated, increasing risk of food borne illness.
Kitchen walls, door frames, ceiling tiles, light fixtures, and air vents were dirty, stained, damaged, or missing, compromising sanitary conditions.
Dietary staff failed to wash hands properly before handling food and clean equipment, risking contamination.
Report Facts
Residents potentially affected: 62
Meal trays on 200 Hall: 11
Meal trays on 200 Hall (second cart): 11
Meal trays on 400 Hall: 13
Meal trays on 300 Hall: 13
Meal trays on 300 Hall (breakfast): 14
Food temperatures: 90.8
Food temperatures: 170
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Provided information on food temperatures, food storage, and facility policies | |
| Certified Nursing Assistant (CNA) #1 | Delivered unheated food cart to 200 Hall | |
| Certified Nursing Assistant (CNA) #2 | Delivered unheated food carts to 200 Hall and breakfast meal to 200 Hall | |
| Certified Nursing Assistant (CNA) #3 | Delivered unheated food carts to 300 and 400 Halls | |
| Certified Nursing Assistant (CNA) #4 | Delivered unheated food carts to 300 Hall for breakfast meals | |
| Dietary Employee (DE) #1 | Observed failing to wash hands properly before handling food and equipment |
Inspection Report
Routine
Deficiencies: 9
Date: Feb 2, 2024
Visit Reason
The inspection was conducted to assess compliance with Medicare/Medicaid regulations, including resident care, environment, safety, and food service standards.
Findings
The facility was found deficient in multiple areas including failure to notify residents of Medicare non-coverage, unsafe and unsanitary environmental conditions in resident rooms, incomplete care plans for oxygen use, inadequate personal hygiene assistance, unsecured hazardous chemical storage, improper respiratory equipment storage, unlocked medication storage, and food safety violations including improper food temperatures, expired and unlabeled food items, unsanitary kitchen conditions, and poor hand hygiene among dietary staff.
Deficiencies (9)
Failed to provide notification of Medicare non-coverage to residents discharged from Medicare Skilled services.
Failed to maintain a safe, functional, sanitary, and homelike environment in 15 resident rooms with damaged walls, missing trim, and residue buildup.
Failed to develop and implement a comprehensive care plan addressing oxygen use for a resident.
Failed to provide adequate personal care resulting in unclean hair and unshaven facial hair for a resident.
Failed to ensure janitor closet, treatment nurse office, and laundry door with chemicals were locked to prevent resident access.
Failed to properly store respiratory equipment (BiPAP, CPAP masks and oxygen tubing) in closed bags or containers to prevent cross contamination.
Failed to store drugs and biologicals in locked compartments; treatment nurse office was unlocked and accessible.
Failed to serve meals at safe and appetizing temperatures; multiple food items served below recommended temperatures.
Failed to ensure food in storage areas was covered, sealed, dated, and stored in sanitary conditions; expired food not removed; kitchen and dishwashing areas had unsanitary conditions and maintenance issues; dietary staff failed to follow proper hand hygiene.
Report Facts
Residents affected: 15
Residents affected: 12
Residents affected: 31
Residents affected: 18
Residents affected: 7
Food trays: 11
Food trays: 13
Food trays: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping #1 | Housekeeping Staff | Acknowledged janitor closet should be locked for resident safety |
| Housekeeping Supervisor | Housekeeping Supervisor | Attempted to lock janitor closet and acknowledged it should be locked at all times |
| Treatment Nurse | Treatment Nurse | Acknowledged treatment nurse office door should be locked at all times |
| Director of Nursing | Director of Nursing (DON) | Confirmed doors with chemicals should be locked and explained consequences if residents access chemicals |
| Lead Certified Nursing Assistant | Lead CNA | Confirmed CPAP mask should be stored in a bag after use |
| Licensed Practical Nurse #1 | LPN | Stated CPAP mask should be put in a plastic bag to prevent contamination |
| Dietary Supervisor | Dietary Supervisor | Provided food temperature readings and facility policies on hand washing and food storage |
| Dietary Employee #1 | Dietary Employee | Observed contaminating food and improper hand hygiene |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 2, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety, nutritional standards, and sanitary conditions in the facility's kitchen and food service areas during observed meals.
Findings
The facility failed to ensure meals were served at acceptable temperatures, food items were properly stored, covered, sealed, and dated, and that kitchen and food preparation areas were maintained in sanitary conditions. Dietary staff also failed to follow proper handwashing protocols, increasing the risk of foodborne illness.
Deficiencies (4)
Meals were served at temperatures below acceptable levels, potentially affecting nutritional intake for multiple residents.
Foods stored in dry storage, refrigerator, and freezer were not properly covered, sealed, or dated, increasing risk of foodborne illness.
Kitchen walls, door frames, ceiling tiles, and light fixtures were not maintained in clean, sanitary conditions and had damage such as chipped paint and rust.
Dietary staff failed to wash hands properly before handling clean equipment and food items, risking contamination.
Report Facts
Residents affected: 11
Residents affected: 13
Residents affected: 13
Residents affected: 13
Residents affected: 62
Food tray counts: 11
Food tray counts: 13
Food tray counts: 13
Food tray counts: 13
Food tray counts: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor | Provided information on food temperatures, storage, and facility policies | |
| Dietary Employee #1 | Dietary Employee | Observed failing to wash hands properly before handling food and equipment |
| Certified Nursing Assistant #1 | CNA | Delivered unheated food cart to 200 Hall |
| Certified Nursing Assistant #2 | CNA | Delivered unheated food carts to 200 Hall and breakfast meal on 01/30/24 |
| Certified Nursing Assistant #3 | CNA | Delivered unheated food carts to 300 and 400 Halls |
| Certified Nursing Assistant #4 | CNA | Delivered unheated food carts to front and back of 300 Hall for breakfast |
Inspection Report
Routine
Deficiencies: 9
Date: Feb 2, 2024
Visit Reason
The inspection was conducted to assess compliance with Medicare/Medicaid regulations, including resident care, safety, environment, and food service standards.
Findings
The facility was found deficient in multiple areas including failure to notify residents of Medicare non-coverage, unsafe and unsanitary environmental conditions in resident rooms, incomplete care plans for oxygen use, inadequate personal hygiene assistance, unsecured hazardous areas, improper storage and handling of respiratory equipment, unlocked medication storage, and food safety violations including improper food temperatures, expired and unlabeled food items, unsanitary kitchen conditions, and poor hand hygiene among dietary staff.
Deficiencies (9)
Failed to provide notification of Medicare non-coverage to residents and/or responsible parties for continued care after Medicare coverage ended.
Failed to maintain a safe, functional, sanitary, and homelike environment in multiple resident rooms with damaged walls, missing trim, and residue buildup.
Failed to ensure comprehensive care plan addressed oxygen use for continuity of care for a resident with physician orders for oxygen.
Failed to provide adequate personal hygiene assistance resulting in a resident having greasy hair and unshaven facial hair.
Failed to secure janitor closet, treatment nurse office, and laundry door containing chemicals, posing risk of accidental ingestion.
Failed to properly store respiratory equipment (BiPAP, CPAP masks and oxygen tubing) in closed bags or containers to prevent cross contamination.
Failed to ensure drugs and biologicals were stored in locked compartments; treatment nurse office was unlocked and accessible.
Failed to serve meals at safe and appetizing temperatures; multiple food items served below recommended temperatures.
Failed to ensure food items in storage were covered, sealed, and dated; kitchen and storage areas had unsanitary conditions including dirty ceiling vents, missing tiles, rust, and grime; dietary staff failed to follow proper hand hygiene.
Report Facts
Residents affected: 3
Residents affected: 15
Residents affected: 1
Residents affected: 1
Residents affected: 18
Residents affected: 3
Residents affected: 62
Food trays: 11
Food trays: 13
Food trays: 13
Food trays: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Acknowledged importance of storing CPAP/BiPAP masks in plastic bags to prevent contamination |
| Housekeeping #1 | Stated janitor closets need to be locked for resident safety | |
| Housekeeping Supervisor | Acknowledged janitor closet doors should be locked at all times due to chemicals | |
| Treatment Nurse | Acknowledged treatment nurse office door should be locked at all times | |
| Dietary Supervisor | Provided policy and observations related to food safety and hand hygiene | |
| DE #1 | Dietary Employee | Observed failing to wash hands before handling clean equipment and food |
| Lead CNA | Certified Nursing Assistant | Described resident hygiene status and assisted with bathing Resident #160 |
| Director of Nursing | DON | Confirmed care plan requirements for oxygen use and hygiene, and importance of locked chemical rooms |
| Administrator | Provided policy information and acknowledged maintenance issues |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Nov 10, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations at The Springs Broadway nursing home.
Findings
The facility was found deficient in multiple areas including failure to consistently use positioning devices to prevent contractures, improper catheter care risking urinary tract infections, inadequate labeling of feeding tube bags, incorrect oxygen administration, failure to serve dairy products as per menu, serving meals at unsafe temperatures, and poor food storage and hygiene practices in the kitchen.
Deficiencies (7)
Failure to ensure splints, hand rolls, or positioning devices were consistently used to prevent decline in range of motion for residents with contractures.
Failure to maintain indwelling catheter to ensure urinary flow was not obstructed, risking urinary tract infection.
Failure to properly label Percutaneous Endoscopic Gastrostomy (PEG) tube feeding bags to prevent contamination and infection.
Failure to administer oxygen as ordered by physician.
Failure to serve dairy products in accordance with the planned menu, affecting nutritional needs.
Failure to serve meals at acceptable temperatures to improve palatability and encourage nutritional intake.
Failure to ensure foods stored in freezer, refrigerator, and dry storage were covered, sealed, and dated; expired products were not promptly discarded; and dietary staff failed to wash hands between tasks, risking foodborne illness.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Meals observed: 2
Census: 70
Expired food items: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Interviewed regarding Resident #7 and Resident #42 contracture care and positioning devices |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding Resident #29 catheter care and drainage |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding Resident #70 feeding tube labeling and oxygen administration |
| Dietary Supervisor | Interviewed and observed regarding meal service, food temperatures, and kitchen food storage | |
| Dietary Employee #1 | Observed washing blender parts and failing to wash hands before handling clean equipment | |
| Dietary Employee #2 | Observed serving lunch trays and failing to wash hands before handling clean equipment | |
| Assistant Director of Nursing | ADON | Observed and interviewed regarding meal temperatures |
| Director of Nursing | DON | Interviewed regarding Resident #42 contracture care and use of hand rolls |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Nov 10, 2022
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to consistently use positioning devices to prevent contractures, improper catheter care risking urinary tract infections, inadequate labeling of feeding tube bags, incorrect oxygen administration, failure to serve dairy products as per menu, serving meals at unsafe temperatures, and poor food storage and hygiene practices in the kitchen.
Deficiencies (7)
Failure to ensure splints, hand rolls, or positioning devices were consistently used to prevent decline in range of motion for residents with contractures.
Failure to maintain indwelling catheter to ensure urinary flow was not obstructed, risking urinary tract infection.
Failure to properly label Percutaneous Endoscopic Gastrostomy (PEG) tube feeding bags to prevent contamination and infection.
Failure to administer oxygen as ordered by the physician.
Failure to serve milk with breakfast as per planned menu.
Failure to serve meals at acceptable temperatures to improve palatability and encourage nutritional intake.
Failure to ensure foods stored in freezer, refrigerator, and dry storage were covered, sealed, and dated; expired items were not promptly discarded; and dietary staff did not follow proper handwashing and food handling procedures.
Report Facts
Residents affected: 58
Total census: 70
Temperature readings: 70
Temperature readings: 110
Expiration dates: Oct 11, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding feeding tube formula labeling and oxygen administration |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding catheter placement and drainage |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding residents' contractures and positioning devices |
| Dietary Supervisor | Interviewed regarding meal service, food storage, and food temperatures | |
| Dietary Employee #1 | Observed and interviewed regarding handwashing and food equipment handling | |
| Dietary Employee #2 | Observed and interviewed regarding handwashing and food serving practices | |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Observed delivering food trays |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed delivering food trays |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed delivering food trays |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Observed delivering food trays |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding food temperature and palatability |
| Director of Nursing | Director of Nursing | Interviewed regarding resident contracture care |
| Chief Nursing Officer | Chief Nursing Officer | Provided facility policies on mobility, catheter care, feeding tube, and oxygen administration |
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