Orinda Care Center, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to accurately assess two of three sampled residents (Resident 13 and Resident 23) for tobacco use status on comprehensive Minimum Data Set (MDS, an assessment used to guide care). Facility inaccurately coded NO to Current Tobacco Use for Resident 13 and Resident 23 who were smoking daily. The failure resulted in inaccurate reflection of Resident 13 and Resident 23's clinical status and placed them at risk for not receiving person-centered care. Findings: During a record review of Resident 13's admission Record, printed on 1/24/25, the record indicated Resident 13 was admitted to the facility on [DATE]. During a record review of Resident 23's admission Record, printed on 1/24/25, the record indicated Resident 23 was admitted to the facility on [DATE]. During an observation on 1/22/25, 1/23/25, 1/24/25 at 10:10 a.m., 1:19 a.m., and 10:16 a.m. respectively, Resident 13 and Resident 23 were observed smoking at facility's patio. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to have Registered Nurse (RN) coverage for at least eight (8) consecutive hours a day for a total of 11 days. This deficient practice had the potential to cause delayed delivery of necessary assessment and treatment services for resident's day-to-day care. Findings: During a record review of the facilities Payroll Based Journal (1/2024 - 12/2024) was reviewed, which indicated the facility did not use the services of an RN for at least eight consecutive hours a day on the following dates: 1/13/24, 1/27/24, 2/11/24, 2/17/24, 2/25/24, 3/2/24, 3/3/24, 3/30/24, 7/21/24, 7/28/24, and 8/31/24. During a concurrent interview and record review on 1/23/25 at 1:53 p.m. with the Administrator (ADM), the facility payroll document titled NHPPD SNF CNA/RNA HOURS, dated 1/13/24 - 8/31/24 was reviewed. The ADM acknowledged there was not an RN in the facility for eight consecutive hours a day on the following days: 1/13/24, 1/27/24, 2/11/24, 2/17/24, 2/25/24, 3/2/24, 3/3/24, 3/30/24, 7/21/24, 7/28/24, and 8/31/24. The ADM stated this practice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure pharmacy services policies and procedures were followed when: 1. Licensed Vocational Nurse (LVN) 1 left the medication cart unlocked and unattended in the hallway. 2. The refrigerator for medication was not maintained within the required temperature range of 36°F to 46°F as outlined in the facility policy and procedure. These failures had the potential for loss or misuse of medications and the potential to jeopardize the residents' health and safety due to improper storage conditions. Findings: 1. During an observation on 1/21/25, at 2:55 p.m., medication cart II was unlocked, unsupervised and unattended with drawers facing the hallway directly outside the dining and activity room. During a concurrent observation and interview with LVN 1 on 1/21/25 at 2:57 p.m., LVN 1 returned to the medication cart II then proceeded to lock the cart. LVN 1 stated, she did not ensure it fully locked prior to leaving medication cart II unattended. LVN 1 further added, it was important to keep medication cart locked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to comply with Health Insurance Portability and Accountability Act (HIPAA) to protect Resident-identifiable information, including but not limited to full name, date of birth (DOB), and clinical status. Clinical staff including attending physician, nurses, nursing managers; and non-clinical staff including Administration, medical records personnel used their personal cell phones to exchange residents' Protected Health Information (PHI) and confidential biographical details and received text messages for above details even when they were off duty. This failure posed a potential significant risk to protect the privacy and security of facility's residents' information. Findings: During an interview and record review with Licensed Vocational Nurse (LVN) 1 on 1/24/25 at 12:17 p.m., Resident 249's clinical chart for pain management was reviewed. LVN 1 stated she was aware of Resident 249's complaints of pain as she had notified the doctor about it. When asked to show the communication between LVN 1 and Resident 249's doctor, LVN 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control prevention practices when: 1. Resident 11's nasal cannula (nc, a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing was undated and unlabeled. 2. LVN (Licensed Vocational Nurse) 3 did not properly disinfect stethoscope (a device used to amplify internal body sounds) between residents. 3. Housekeeping Manager (HKM) held Resident 14's clean blankets against her clothing during transport to Resident 14's room. These failures had the potential for cross contamination and spread of infections among residents at the facility. Findings: 1. During a review of Resident 11's admission record, dated 1/23/25, indicated Resident 11 was admitted to the facility on [DATE]. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated assessment tool) dated, 12/27/24, indicated Resident had multiple diagnoses that included, Asthma (lung condition that causes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care with dignity for one of three sampled residents (Resident 18) when two facility staff did not provide privacy for Resident 18 during nursing care. This deficient practice resulted in not ensuring resident 18's right to be treated with dignity and respect. Findings: During a review of Resident 18's admission record, dated, 1/23/25, the admission record indicated Resident 18 was admitted to the facility on [DATE] and was re-admitted on [DATE]. During a review of Resident 18's Minimum Data Set (MDS, a federally mandated assessment tool), dated 11/17/24, indicated Resident 18 had multiple diagnoses which included progressive neurological conditions (type of illness that affects the nervous system like brain, spinal cord, or nerves and gets worse over time) that included cerebral palsy (condition that affects posture and movement), quadriplegia [(condition characterized by the loss of impairment of movement and sensation in all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure an assessment and/or an evaluation for self-administration of medications was completed for one of 46 sampled residents (Resident 11) when the following were observed on Resident 11's bedside table: a. a bottle of Nystatin (antifungal antibiotic topical treatment) powder b. one cup filled with Pepto Bismol (oral medication used for heartburn, indigestion, diarrhea, and nausea) c. Sudafed (allergy) Nasal Spray This facility failure increased the potential for the unsafe self-administration of medications. It also had the potential to result in the use of the medications by other residents, who could come into the room and obtain the treatment from the bedside table where it was stored. Findings: During a review of Resident 11's admission record, dated 6/23/25, the admission record indicated, Resident 11 was admitted to the facility on [DATE], with multiple diagnoses that included, mild cognitive impairment of uncertain or unknown…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete quarterly Minimum Data Set (MDS, a resident assessment used to guide resident's care, Quarterly MDS assessment is used to track a resident's status between comprehensive assessment to ensure resident's gradual change in status are monitored) assessment in a timely manner for one of two sampled residents (Resident 28) for over four months. This deficient practice resulted in Resident 28 not receiving the assessment and placed her at risk for not receiving appropriate care and services based on her health status. Findings: During a review of Resident 28's admission Record printed on 6/22/25 indicated Resident 28 was admitted to the facility on [DATE]. During an interview and record review on 1/23/25 at 10:50 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 28's MDS assessment history was reviewed. MDSC stated he missed to complete Resident 28's Quarterly assessment in 10/2024.The MDSC stated he did not assess Resident 28 after…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident's (Resident 14) Pre-admission Screening Resident Review (PASARR-Preadmission Screening and Resident Review is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) for serious mental illness was accurately completed and sent to the appropriate state mental authority for Level II evaluation and determination. This failure had the potential to prevent Resident 14 from receiving appropriate required mental health services. Findings: During a record review of Resident 14's admission Record, printed 1/23/25, it indicated Resident 14 was admitted to the facility on [DATE] with diagnoses including epilepsy (a brain disorder in which a person has repeated seizures over time. Seizures are episodes of uncontrolled and abnormal firing of brain cells that may cause changes in attention or behavior such as bodily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure/perform a Pre-admission Screening and Resident Review (PASARR-a screening tool to determine if individuals with serious mental illness or intellectual/developmental disability or related condition require nursing facility services or specialized services) for one (Resident 2) of four sampled residents. This failure had the potential to result in Resident 2 not being provided specialized care and services to address a mental illness. Findings: During a record review of the Resident 2's admission Record, printed 1/23/25, it indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), paranoid schizophrenia (a mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior), epilepsy (a brain disorder in which a person has repeated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide an alternative for use of splint (a medical device used to support and immobilize a part of the body, to promote healing and reduce pain) for over a month, for one of 14 sampled residents (Resident 38) to manage left hand deformity, when Resident 38 refused to wear a splint. Resident 38 stated he had a history of plate implant surgery on his left hand. This failure resulted in Resident 38 to experience pain when he used his left hand to wheel the wheelchair and potential risk for skin breakdown of his left hand while pushing the wheelchair. Findings: During a record review of Resident 38's admission Record (admission Record is a document used to communicate basic information about a resident) printed on 1/21/25, the record indicated Resident 38 was admitted to the facility 10/11/24. During a review of Resident 38's Minimum Data Set (MDS is a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 10/17/24, the assessment indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure range of motion (ROM) exercises were provided for two of five sampled residents (Resident 6 and 18) reviewed for limited ROM. This failure had the potential to result in decline in the Resident 6 and Resident 18's ROM. Findings: a. During a review of Resident 6's admission record, dated 1/23/25, the admission record indicated Resident 6 was admitted to the facility on [DATE]. During a review of Resident 6's MDS, dated , 1/7/25, the MDS revealed, Resident 6 had a Brief Interview for Mental Status (BIMS, an assessment tool used by the facilities to screen and identify memory, orientation, and judgment status of the resident) Score of 5/15, meaning, Resident 6's cognition was severely impaired. The MDS indicated, Resident 6 had multiple diagnoses that included progressive neurological conditions Cerebrovascular Accident (CVA, stroke) and muscle weakness. The MDS also indicated, Resident 6 had functional limited range of motion on both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow up on one of 14 sampled residents (Resident 249)'s request to change routine pain medication (Oxycodone) from every six hours to every four hours. This failure resulted in Resident 249 to experience unrelieved pain and made him feel frustrated and unhappy. Findings: During a record review of Resident 249's admission Record (admission Record is a document used to communicate basic information about a resident) printed on 1/21/25, the record indicated Resident 249 was admitted to the facility on [DATE] and Resident 249 had a Diagnosis of Acquired absence of left leg above knee. During a review of Resident 249's Minimum Data Set (MDS is a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 1/15/25, the assessment indicated Resident 249 was able to speak clearly, understand others and make himself understood. The Brief Interview for Mental Status (BIMS) Score for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to plan and implement parameters for Glargine insulin (a type of insulin helps maintain blood glucose levels throughout the day and night) administration for one of six sampled residents (Resident 7) for over five months period. Resident 7 received insulin for certain blood glucose levels on some days and did not on other days. The failure placed Resident 7 at risk for not receiving insulin as needed and posed risk for hyperglycemia (high blood glucose) or hypoglycemia (a condition which blood glucose is too low). Findings: During a review of admission Record printed on 1/24/25, Resident 7 was admitted to the facility on [DATE]with diagnosis of Type 2 diabetes mellitus (a form of diabetes) with hyperglycemia. During a record review, Resident 7's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) assessment was reviewed. MDS assessment indicated that Resident 7 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure one of two sampled residents was free from significant medication errors when the facility incorrectly reconciled and transcribed the dosage of a prescribed anti-seizure (seizures are episodes of uncontrolled and abnormal firing of brain cells that may cause changes in attention or behavior such as bodily movements) medication to Resident 99. Licensed nursing staff then administered the incorrect dosage of the medication to Resident 99 for a period of 22 days. This failure resulted in Resident 99 experiencing multiple seizures, hospitalization, and death. Findings: During a record review of Resident 99's Administration Record, printed on August 21, 2024, it indicated Resident 99 was admitted to the facility on [DATE], with diagnoses including non-traumatic intracranial hemorrhage (a life-threatening condition that occurs when there's bleeding in or around the brain), malignant neoplasm of the brain (a cancerous brain tumor),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for safety when a resident food refrigerator contained items that were not labeled and/or dated. This failure put 41 of 45 residents who can access the resident refrigerator at increased risk for food contamination and foodborne illness. Findings: During an interview on 10/17/23 at 2:31 p.m. with Certified Nurse Assistant (CNA) 3, CNA 3 stated outside food must be labeled with resident's room number and last name. During an interview on 10/17/23 at 3:00 p.m. with Director of Nursing (DON), DON stated the expectation is for staff to store resident food appropriately by labeling it with resident name and date before placing it in the refrigerator. During a concurrent observation and interview on 10/17/23 at 3:09 p.m. with DON, in the medication room, a resident refrigerator/freezer contained a straw-textured bag with drinks and a clear plastic bowl covered with tin foil that contained a partially eaten salad. DON stated the items belonged to a resident and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation interview and record review, the facility failed to ensure infection control practices were implemented when staff did not wear a gown while handling residents' dirty laundry and soiled linens for 45 of 45 residents. This failure placed the facility's residents at risk for healthcare-associated infections. Findings: During a concurrent observation and interview on 10/18/23 at 10:59 a.m. with Housekeeping Manager (HSKM), in the laundry room, gowns were not available for use in the work area. HSKM stated staff needed to wear a gown to prevent contact with soiled linens, which contaminated clean linens. During an interview on 10/18/23 at 10:59 a.m. with Housekeeper (HSKP), HSKP stated there were no gowns available and she did not wear a gown when she started the two loads of laundry in the dryer. During an interview on 10/18/23 at 2:22 p.m. with Infection Preventionist (IP), IP stated the expectation for staff in laundry was to wear personal protective equipment (PPE - equipment worn to minimize exposure or spread of infection or illness) when handling dirty…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide grooming to one of 12 sampled residents (Resident 37), when they did not shave their facial hair. This failure had the potential to cause Resident 37 to feel undignified and upset. During a review of Resident 1's Minimum Data Set (MDS - an assessment tool used to guide care), dated 9/5/23, the MDS indicated Resident 37 was admitted 8//23 and was a female. The MDS also indicated Resident 37 had a Brief Interview for Mental Status (BIMS - a tool used to assess mental function) score of 12, meaning moderately impaired. Additionally, the MDS indicated Resident 37 needed extensive assistance (resident involved in activity, staff provide weight-bearing support), from one person to shave and complete personal hygiene. During a concurrent observation and interview on 10/16/23, at 10:27 a.m., Resident 37 was observed with hair on their chin, cheeks, and upper lip. Resident 37 stated their facial hair was too long and they told staff last week that they wanted to shave, but they wouldn't do it. Resident 37…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation when: 1. Dietary [NAME] (DC)1 did not perform hand hygiene while handling and preparing chicken puree. 2. Food preparation sink and ice machine did not have an air gap (a gap created to prevent back flow of contaminated water). These failures had the potential to cause food contamination and food born illnesses in residents. Findings: 1. During a observation and concurrent interview on 04/05/21, at 11:46 a.m., with DC 1, in the kitchen, a blender (mixer) filled with chicken was running on the kitchen countertop on the left side of the tray line. DC 1 was observed with blue colored gloves on both hands. DC1 touched the stove regulator (dials to control the stove heat temperature) with gloved hands, then picked up a glass measuring cup, proceeded to the dirty dish washing sink, turned on the faucet, half-filled the measuring cup with water from the sink faucet designated for washing dirty dishes, and then turned the faucet off. DC 1 proceeding to the tray line , turned…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents' food brought from outside was labeled and stored appropriately in one of one residents' food refrigerator and freezer. This failure had the potential to cause food contamination and food borne illnesses in residents. Findings: During a concurrent observation and interview, on 4/6/21, at 11:37 a.m., with Certified Nursing Assistant (CNA 1) and the Director of Staff Development/Infection Control Preventionist (DIC), in facility's copy room, the facility's refrigerator and freezer designated for residents' food brought from outside stored the following items: a. An unlabeled, undated 12 (ounces) oz jar of organic apricot fruit spread, 16 oz of chunky blue cheese dressing, 6 oz of hot sauce. CNA 1 stated she did not know who these food items belonged to. b. A 20 oz coffee drink, CNA 1 stated the coffee drink belonged to her. CNA 1 stated she was not sure if staff could keep their food in resident's food refrigerator. c. An unlabeled, undated, partially eaten meat pizza slice, on a disposable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow its policy in verifying the effectiveness of Spirit II disinfectant against the bacterial organism found in one (Resident 18) of 39 sampled residents . This failure had the potential to result in the spread of Enterobacter Cloacae(member of the normal gut flora) which could result in the infection of additional residents, possible facility outbreak, and the possibility of resident death. Findings: Review of Resident's 18's face sheet dated 1/16/20, indicated Resident 18 was admitted to the facility with a diagnosis of chronic hepatitis C (infection caused by a virus that attacks the liver that can lead to an infection), cancer of the skin and gastro-esophageal reflux disease (a condition in which acidic gastric fluid flows backward into the esophagus (connects the throat to the stomach) causing heart burn without esophagitis. During an interview on 04/06/2021, at 9:30 a.m., with the Director of Staff Development/Infection Preventionist Consultant (DIC), the DIC stated that Resident 18 had bacteria…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.