Inspection Reports for Hickory Creek at Sunset
1109 S Indiana St, Greencastle, IN 46135, United States, IN, 46135
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 4, 2025, identified deficiencies related to unsafe wheelchair transportation that resulted in a resident fall and injury. Earlier inspections showed a pattern of deficiencies involving resident care issues such as dignity during meal service, medication management, psychosocial support, and transportation assistance, as well as life safety code violations including sprinkler system maintenance and fire safety equipment. Complaint investigations were mostly unsubstantiated, except for a few substantiated cases tied to resident rights and care concerns. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with resident care and safety, with some corrective actions noted but no clear trend of consistent improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
121% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 5, 2025
Visit Reason
The inspection was conducted following a complaint related to a resident fall incident involving unsafe wheelchair transport that resulted in injury.
Complaint Details
This citation relates to Complaint IN00451216.
Findings
The facility failed to ensure a resident was safely transported in her wheelchair, resulting in a fall and nasal fracture. The incident occurred when the resident's foot caught on a dip in the floor while being pushed in a wheelchair without foot pedals. The deficient practice was corrected prior to the survey with implementation of foot pedal use and staff training.
Deficiencies (1)
Failed to ensure a resident was safely transported in her wheelchair, resulting in a fall and nasal fracture.
Report Facts
Residents reviewed for accidents: 3
Date of fall event: Jan 10, 2025
Date deficient practice corrected: Jan 22, 2025
Date of admission MDS assessment: Dec 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 4 | Certified Nurse Aide | Interviewed regarding the fall incident and foot pedal use. |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding foot pedal requirements for residents. |
| CNA 5 | Certified Nurse Aide | Bus driver on the day of the resident's fall, described the incident and precautions. |
| Executive Director | Executive Director | Provided information on facility policy changes regarding wheelchair foot pedals. |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 1
Date: Feb 4, 2025
Visit Reason
This visit was conducted for the investigation of Complaints IN00451961 and IN00451216. Complaint IN00451216 resulted in federal/state deficiencies being cited related to accident hazards and supervision.
Complaint Details
Complaint IN00451216 was substantiated with federal/state deficiencies cited. Complaint IN00451961 had no deficiencies related to the allegations.
Findings
The facility failed to ensure a resident was safely transported in her wheelchair, resulting in a fall and nasal fracture for one resident. The incident involved the resident's foot catching on a dip in the floor while being pushed in a wheelchair without foot pedals, causing the resident to fall and sustain injuries. The deficient practice was corrected prior to the survey.
Deficiencies (1)
Failure to ensure a resident was safely transported in her wheelchair, resulting in a fall and nasal fracture.
Report Facts
Census: 51
Total Capacity: 51
Medicare Census: 4
Medicaid Census: 36
Other Payor Census: 11
Date of Fall Incident: Jan 10, 2025
Date Deficient Practice Corrected: Jan 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) 4 | Interviewed regarding fall incident and wheelchair foot pedals | |
| Licensed Practical Nurse (LPN) 3 | Interviewed regarding wheelchair foot pedal requirements | |
| Certified Nurse Aide (CNA) 5 | Bus driver on day of resident fall incident | |
| Executive Director (ED) | Interviewed regarding facility policy on wheelchair foot pedals |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Date: Nov 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444857.
Complaint Details
Complaint IN00444857 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00444857 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 5
Medicaid census: 34
Other payor census: 11
Inspection Report
Re-Inspection
Census: 48
Capacity: 68
Deficiencies: 0
Date: Oct 29, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The building is fully sprinklered except for three detached buildings used for employee lounge, maintenance, and storage.
Report Facts
Facility capacity: 68
Census: 48
Inspection Report
Life Safety
Census: 55
Capacity: 68
Deficiencies: 3
Date: Sep 30, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 09/30/2024.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to maintain automatic sprinkler systems per NFPA 25, use of extension cords as substitutes for fixed wiring, and failure to ensure the oxygen trans-filling room door latched properly.
Deficiencies (3)
Failed to maintain automatic sprinkler systems in accordance with NFPA 25; two of four sampled sprinklers failed inspection.
Extension cords were used as a substitute for fixed wiring in resident rooms, specifically an extension cord found in resident room 16.
Oxygen trans-filling room door did not latch into the door frame as required for fire-resistive construction.
Report Facts
Certified beds: 68
Census: 55
Deficiencies cited: 3
Sprinkler sample failures: 2
Residents potentially affected: 20
Residents potentially affected: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tega Brume | Executive Director | Named during exit conference and plan of correction |
| Maintenance Director | Interviewed and involved in findings and corrective actions |
Inspection Report
Annual Inspection
Census: 53
Capacity: 53
Deficiencies: 4
Date: Sep 11, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00442274 and IN00442280.
Complaint Details
Complaint IN00442274 - No deficiencies related to the allegations were cited. Complaint IN00442280 - Federal/State deficiencies related to the allegations were cited at F550 (Resident Rights).
Findings
The facility was found deficient in ensuring resident rights during meal service, accuracy of Minimum Data Set (MDS) assessments, proper medication labeling and storage, and hand hygiene during meal service. Complaint IN00442274 had no deficiencies, while Complaint IN00442280 resulted in deficiencies related to resident rights.
Deficiencies (4)
Failure to ensure the dignity of a resident during meal service, including delayed meal delivery and lack of tray service.
Failure to ensure a Minimum Data Set (MDS) assessment was coded correctly for a resident regarding eating assistance.
Failure to ensure medications and biologicals were dated when opened and to properly dispose of discontinued medication.
Failure to ensure proper handwashing procedure during meal service.
Report Facts
Census: 53
Total Capacity: 53
Survey Dates: 5
Residents requiring eating assistance reviewed: 19
Medication carts observed: 2
Medication rooms observed: 1
Medication expiration days: 28
Medication expiration days: 30
Medication expiration days: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tega Brume | Executive Director | Signed report and provided interview regarding meal service and resident rights |
| Certified Food Manager (CFM) | Interviewed regarding meal preparation and delivery delay for Resident B | |
| Registered Nurse 4 | Interviewed regarding medication storage and expiration practices | |
| Director of Nursing (DON) | Provided policies and interviews regarding medication storage and hand hygiene | |
| Nursing Assistant in Training (NAIT) 5 | Observed and interviewed regarding meal service and handwashing deficiencies | |
| MDS Coordinator | Interviewed regarding MDS assessment coding errors | |
| Corporate RAI Specialist | Interviewed regarding proper MDS coding standards |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00442280 completed on September 11, 2024.
Complaint Details
Investigation of Complaint IN00442280 was included in the review and found to be in compliance.
Findings
Hickory Creek at Sunset was found to be in compliance with 42 CFR Part 483, Subpart B and IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey and the Investigation of Complaint IN00442280.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 5, 2024
Visit Reason
The inspection was conducted in response to a complaint (IN00442280) regarding the facility's failure to honor a resident's right to a dignified existence and to exercise her rights during meal service.
Complaint Details
This citation relates to Complaint IN00442280. The complaint involved Resident B's meal being delayed despite prior request for a hamburger substitute, and the resident was not offered alternative food while waiting.
Findings
The facility failed to ensure the dignity of Resident B during meal service when her requested meal substitute was delayed, and she was not offered alternative food while waiting. Interviews with the resident, Certified Food Manager, and Executive Director confirmed the delay and lack of offered alternatives.
Deficiencies (1)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise her rights during meal service.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NAIT 5 | Nursing Assistant in Training | Assisted Resident B with drinks and meal tray during the lunch meal observation. |
| Certified Food Manager | Interviewed regarding the meal request and delivery of hamburger. | |
| Executive Director | Interviewed regarding staff offering cottage cheese to Resident B during meal delay. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 5, 2024
Visit Reason
The inspection was conducted in response to a complaint (IN00442280) regarding the dignity of a resident during meal service and medication storage and labeling practices.
Complaint Details
This citation relates to Complaint IN00442280 regarding the dignity of a resident during meal service and medication storage and labeling.
Findings
The facility failed to ensure the dignity of a resident during meal service, proper handwashing technique by staff during meal service, and proper labeling and disposal of medications and biologicals. Specific issues included delayed meal service for a resident, improper handwashing by a Nursing Assistant in Training, and undated or improperly stored medications.
Deficiencies (3)
Failed to ensure the dignity of a resident during meal service for 1 of 2 dining observations (Resident B).
Failed to ensure medications and biologicals were dated when opened and failed to properly dispose discontinued medication for medication carts and medication rooms observed.
Failed to ensure proper handwashing procedure during meal service for 1 of 2 dining observations.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Assistant in Training (NAIT) 5 | Assisted Resident B during meal service and observed washing hands improperly | |
| Registered Nurse (RN) 4 | Interviewed regarding medication storage and policies | |
| Director of Nursing (DON) | Provided policies and interviewed regarding medication storage and handwashing | |
| Certified Food Manager (CFM) | Interviewed regarding meal preparation and resident meal request | |
| Executive Director (ED) | Interviewed regarding meal service and facility policies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 30, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00435710 completed on June 28, 2024.
Complaint Details
Investigation of Complaint IN00435710; paper compliance review found the facility in compliance.
Findings
Hickory Creek at Sunset was found to be in compliance with 42 CFR Part 483, Subpart B and IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 28, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about the care and services provided to Resident G, including mental health services, transportation arrangements, and dietary accommodations.
Complaint Details
This citation relates to Complaint IN00435710. The complaint involved Resident G being left unattended in the shower room multiple times, lack of trauma-informed care, failure to assist with transportation from a hospital appointment, and failure to honor dietary preferences.
Findings
The facility failed to provide appropriate mental health services and trauma-informed care to Resident G, left the resident unattended multiple times in the shower room, failed to assist with transportation from a hospital appointment, and did not honor the resident's dietary preferences and dislikes. Documentation and care plans were lacking in these areas.
Deficiencies (3)
Failed to provide appropriate treatment and services to a resident with mental disorder or psychosocial adjustment difficulty, resulting in psychosocial distress.
Failed to help the resident make transportation arrangements to and from radiology services.
Failed to provide food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Report Facts
Residents affected: 1
Duration left unattended: 90
Duration left unattended: 30
Number of times forgotten: 4
Call attempts: 6
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 3
Date: Jun 27, 2024
Visit Reason
This visit was for the investigation of complaints IN00435710, IN00436109, IN00436745, and IN00437354. Deficiencies related to complaint IN00435710 were cited.
Complaint Details
Complaint IN00435710 was substantiated with federal/state deficiencies cited at F742, F778, and F806. Complaints IN00436745, IN00437354, and IN00436109 had no deficiencies related to the allegations.
Findings
The facility was found deficient in ensuring appropriate mental and psychosocial services for a resident with PTSD and anxiety, assisting a resident with transportation arrangements from a hospital appointment, and honoring a resident's dietary dislikes and food preferences. The resident experienced psychosocial distress due to being left unattended in the shower room multiple times, was left without transportation after a hospital MRI appointment, and was served foods he could not tolerate despite communicating his preferences.
Deficiencies (3)
Failed to ensure a resident with PTSD and anxiety received appropriate mental and psychosocial services resulting in psychosocial distress.
Failed to assist a resident in obtaining transportation from a hospital appointment.
Failed to honor a resident's dietary dislikes and food preferences.
Report Facts
Census: 52
Total Capacity: 52
Deficiencies cited: 3
Inspection Report
Complaint Investigation
Census: 43
Capacity: 43
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00430874.
Complaint Details
Complaint IN00430874 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00430874 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 3
Medicaid residents: 27
Other payor residents: 13
Inspection Report
Re-Inspection
Census: 40
Capacity: 68
Deficiencies: 0
Date: Sep 19, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/17/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR survey, Hickory Creek at Sunset was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 37
Capacity: 68
Deficiencies: 4
Date: Aug 17, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 08/17/2023 to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included failure to conduct preventative maintenance for battery-operated smoke alarms according to manufacturer's instructions, installation of mixed sprinkler head types within a smoke compartment, and incomplete documentation of sprinkler system inspections and generator load testing.
Deficiencies (4)
Failure to ensure preventative maintenance for all battery operated smoke alarms in resident rooms was conducted according to manufacturer's published instructions.
Failure to ensure only one type of sprinkler head (quick response or standard) was installed in one of four smoke compartments.
Failure to document sprinkler system inspections in accordance with NFPA 25, including missing weekly dry sprinkler system gauge inspection documentation.
Failure to maintain a complete written record of monthly generator load testing for 1 of 12 months and weekly inspection for 5 of 52 weeks.
Report Facts
Certified beds: 68
Census: 37
Deficiency completion dates: Sep 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tega Brume | Executive Director | Named in relation to exit conferences and corrective action oversight |
| Maintenance Director | Interviewed regarding deficiencies and responsible for corrective actions | |
| Field Maintenance Supervisor | Participated in observations and exit conference |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jul 28, 2023
Visit Reason
The inspection was conducted following a complaint regarding failure to maintain resident dignity and provide proper incontinence care, as well as other care concerns.
Complaint Details
The complaint investigation focused on failure to maintain resident dignity, failure to provide incontinence care, improper respiratory care, medication errors, kitchen hygiene issues, and inaccurate staffing reporting.
Findings
The facility failed to maintain resident dignity by not changing a resident after an incontinence episode before feeding, failed to provide incontinence care for dependent residents, failed to properly store respiratory equipment and follow oxygen orders, had medication administration errors related to insulin, and failed to ensure proper kitchen hygiene and linen handling. Staffing reporting was also found inaccurate for one quarter.
Deficiencies (6)
Failure to ensure a resident's dignity was maintained when the resident was not changed after an incontinence episode and was fed in a soiled brief in her room.
Failure to ensure incontinence care was provided for dependent residents.
Failure to ensure proper storage of respiratory BiPAP equipment and failure to follow physician's oxygen orders.
Medication error rate exceeded 5% related to insulin administration errors including improper technique and timing.
Failure to ensure proper handling of linens in the kitchen and lack of paper towels for proper handwashing.
Failure to accurately report weekend staffing hours in the payroll-based journal reporting system.
Report Facts
Medication errors observed: 3
Insulin administration error rate: 8.57
Blood glucose readings: 259
Blood glucose readings: 212
Blood glucose readings: 354
Insulin doses: 11
Insulin doses: 6
Insulin doses: 6
Insulin doses: 18
Oxygen flow rate: 4
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 17 | Certified Nursing Assistant | Named in failure to provide incontinence care to Resident 5 |
| CNA 10 | Certified Nursing Assistant | Named in failure to provide incontinence care to Resident 5 |
| PT 5 | Physical Therapist | Observed Resident 5 wet and notified staff to change brief |
| RN 11 | Registered Nurse | Observed and administered insulin with errors |
| RN 8 | Registered Nurse/Unit Manager | Interviewed regarding incontinence care and oxygen administration |
| Housekeeper 6 | Housekeeper | Observed carrying linens improperly into kitchen |
| Regional Director of Clinical Operations | Regional Director of Clinical Operations | Provided policies and interviewed about deficiencies |
| Administrator | Administrator | Interviewed about incontinence care incident and staffing reporting |
| Registered Nurse (RN) 8 | Registered Nurse | Observed oxygen administration and reviewed orders |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on July 28, 2023.
Findings
Hickory Creek at Sunset was found to be in compliance with 42 CFR Part 483, Subpart B and IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Annual Inspection
Census: 36
Capacity: 36
Deficiencies: 5
Date: Jul 24, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00413927.
Complaint Details
Complaint IN00413927 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in multiple areas including resident dignity and incontinence care, insulin administration errors, respiratory care, and food safety practices. Complaint allegations were not substantiated. Corrective actions and staff education plans were outlined.
Deficiencies (5)
Failure to ensure a resident's dignity was maintained when the resident was not changed after an incontinence episode and was fed in a soiled brief.
Failure to ensure incontinence care was provided for dependent residents.
Failure to ensure proper storage of respiratory BiPAP equipment and failure to follow physician's order for oxygen therapy.
Medication error rate exceeded 5% related to insulin administration errors.
Failure to ensure proper handling of linens in the kitchen and lack of paper towels for proper handwashing.
Report Facts
Survey dates: 5
Census: 36
Total Capacity: 36
Medication error rate: 8.57
Blood glucose readings: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tega Brume | Executive Director | Signed the report |
| RN 11 | Registered Nurse | Observed administering insulin with errors |
| CNA 17 | Certified Nursing Assistant | Involved in failure to provide timely incontinence care to Resident 5 |
| CNA 10 | Certified Nursing Assistant | Involved in failure to provide timely incontinence care to Resident 5 |
| PT 5 | Physical Therapist | Observed Resident 5 wet and notified staff |
| RN 8 | Registered Nurse/Unit Manager | Interviewed regarding respiratory care and oxygen orders |
| Housekeeper 6 | Observed carrying linens improperly into kitchen | |
| Cook 7 | Observed improper handwashing and handling of towels in kitchen |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 38
Deficiencies: 0
Date: Apr 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00404889 and IN00405624.
Complaint Details
Complaint IN00404889 and Complaint IN00405624 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00404889 and IN00405624 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 38
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 27
Census Payor Type - Other: 9
Inspection Report
Complaint Investigation
Census: 39
Capacity: 39
Deficiencies: 0
Date: Feb 14, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00396121.
Complaint Details
Complaint IN00396121 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00396121 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 39
Total Capacity: 39
Medicare Census: 6
Medicaid Census: 23
Other Payor Census: 10
Inspection Report
Complaint Investigation
Census: 41
Capacity: 41
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00388710 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00388710 was unsubstantiated due to lack of evidence.
Findings
Complaint IN00388710 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation and the COVID-19 survey.
Report Facts
Census SNF/NF beds: 41
Total census: 41
Medicare census: 5
Medicaid census: 26
Other payor census: 10
Inspection Report
Routine
Deficiencies: 3
Date: May 11, 2022
Visit Reason
The inspection was conducted to assess compliance with federal requirements related to pre-admission screening and resident review (PASRR), food procurement and safety, and infection control practices during dining service.
Findings
The facility failed to ensure a timely referral for a PASRR re-evaluation for a resident with new mental health diagnoses, failed to monitor dishwasher sanitization properly for two months, and failed to ensure proper hand hygiene during dining service observations.
Deficiencies (3)
Failed to ensure a referral for a re-evaluation was made to the state designated authority for PASRR for a resident with newly identified mental health diagnoses.
Failed to ensure the dishwasher was monitored for sanitization for 2 of 2 months reviewed.
Failed to ensure hand hygiene was performed during dining service for 2 of 2 dining observations.
Report Facts
Deficiencies cited: 3
Dishwasher temperature: 120
Chlorine ppm: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding PASRR assessment request timing | |
| Certified Nursing Assistant (CNA) 11 | Observed during dining service and hand hygiene practices | |
| Certified Nursing Assistant (CNA) 12 | Observed during dining service | |
| Director of Nursing | Provided facility policy and interviewed regarding hand hygiene practices | |
| Culinary Manager | Interviewed regarding dishwasher sanitization and monitoring | |
| Administrator | Interviewed regarding dishwasher chlorine ppm and policy documents |
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