Facility Evaluation Report

On 6-10-22 at 3:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding incident reports received on 6-10-22. LPA met with Director of Nursing (DON) Lakhibir Kaur, LVN and explained the purpose of the visit. LPA also spoke with Administrator Anuradha Saini via phone and explained the purpose of the visit. LPA reviewed incident reports and test results for Resdient1 (R1), R2, R3, and R4. LPA also interviewed Administrator and DON. Based on interviews and record reviews, it was determined that an occurrence resulting in a suspected flu outbreak occurred on 6-5-22 and not reported to licensing department within 24 hours of occurrence.

Based on today’s visit, deficiency is cited under Title 22, Division 6, Chapter 8. An exit interview was held with Lakhbir Kaur and a copy of this report was left with Lakhbir. Appeal rights provided.