complaint·January 14, 2026

Allegation: “Staff did not ensure resident's hygiene needs were being met” It was reported that resident hygiene needs such as washing hands were not maintained which resulted in Resident #1 (R1) contracting Clostridioides Difficile (C. Diff). Interview with residents revealed no overall concerns about the facility’s cleaning protocols. Residents stated they frequently observe staff cleaning/sanitizing their rooms in addition to common areas. Residents also had no concerns regarding their hygiene needs and expressed that they always feel clean. Residents reported washing their hands as frequently as they can with staff assistance. Staff reported that residents with illnesses or contagious diseases are kept in isolation in their rooms or sent to the hospital. During this time, personal protective equipment (PPE) is provided outside the rooms for staff utilization when providing care. As an extra precaution, typically one (1) staff is assigned to that resident’s care to prevent further contamination. Residents who are symptom free and cleared of their illness will then return to the community and staff then clean the infected rooms which include laundry services and sanitizing/disinfecting all surfaces. During day-to-day operations, the facility’s common areas are cleaned frequently with staff access to cleaning chemicals if needed. Housekeepers and the maintenance team provide deep cleanings during the overnight shifts. Staff reported hand sanitizing stations throughout the facility for everyone to use in addition to following hand washing and glove precautions. Specifically, the MCU utilizes hand wipes before meals to accommodate resident preferences. Record review revealed that R1 experienced a change of condition on 08/29/2024 and was subsequently transferred to the hospital. On 08/31/2024, R1 returned to the facility with an eye infection and was prescribed antibiotics. R1 later tested positive for C. Diff on 09/02/2024, was sent to the hospital, and returned to the facility on 09/17/2024 with negative results. On 10/01/2024, R1 showed symptoms of C. Diff, was transferred to the hospital, and returned to the facility on 10/11/2024. Medication review revealed that R1 was not prescribed antibiotics in August 2024; however, in September 2024 R1 took three (3) antibiotics and two (2) antibiotics in October 2024. Report Continued on LIC 9099-C It was also revealed that Resident #2 (R2) had C. Diff in March 2024 and was sent to the hospital until asymptomatic and returned to the facility and has not had C. Diff since. Furthermore, R1 moved to the MCU from Assisted Living in December 2023, and R2 moved to the MCU from Assisted Living on 02/19/2025. Although it was possible both residents may have been in contact at community events, R1 and R2 were not in contact while actively diagnosed with C. Diff. Per information released by the U. S. Centers for Disease Control and Prevention (CDC) on 12/18/2024, C. Diff is common among individuals in healthcare settings such as hospitals and nursing homes. It is spread from person to person through feces and inactive spores in the environment that can be activated by swallowing the spores. The CDC reported C. Diff infections can also occur when taking antibiotics which result in C. Diff side effects. It was recommended to reduce the spread by washing hands with soap and water after restroom use and before meals. Based on interviews and record review, the facility followed infection control procedures and ensured residents’ hygiene were maintained. Additionally, R1 visited the hospital and was prescribed antibiotics shortly before contracting C. Diff, which may have increased their risk of exposure. Although R1 did contract C. Diff, there is not sufficient evidence to prove the alleged violation was a result of resident hygiene needs being unmet, therefore the allegation is deemed UNSUBSTANTIATED at this time. No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.