Claridge Court

Inspectors wroteThe facility identified a census of 38 residents. The sample included 13, with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure potentially hazardous kitchen equipment in a safe, locked area and out of reach of six cognitively impaired, independently mobile residents. Findings Included: - On 01/12/26 at 07:00 AM, a walkthrough of the facility revealed the hallway door to the kitchen was left fully open. An inspection of the interior kitchen revealed that both interior kitchen doors were left open. No staff were observed in the kitchen or the surrounding dining area. No residents were in or around the kitchen area at the time of observation, but had access to that area. An inspection of the sink area in the kitchen revealed an unsecured lock on a cabinet below the sink. [...]

Inspectors wroteThe facility identified a census of 38 residents. The sample included 13 residents, with one resident reviewed for hospitalization. Based on record review and interviews, the facility failed to provide a written notice of transfer/discharge as soon as practicable, and the facility also failed to provide a bed hold notice with the required information for Resident (R) 20.

Inspectors wroteThe facility identified a census of 38 residents. The sample included 13 residents, with two reviewed for pressure ulcers (localized injuries to the skin and/or underlying tissue, usually over a bony prominence, caused by pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 18's pressure-reducing interventions were implemented correctly when R18's low air-loss mattress (a specialized adjustable air mattress that reduces pressure applied to the body) was not set within her current weight range. [...]

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents and five Certified Nurse Aides (CNAs) reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 37 residents. The facility had one kitchen and one kitchenette. Based on observation, record review, and interviews, the facility failed to ensure that food items were properly stored in a safe and sanitary manner after the original sealed package had been opened. The facility failed to ensure foods were labeled and dated after opening. This placed all residents who ate food from the facility at risk for food-borne illness.

Inspectors wroteThe facility identified a census of 37. The sample included 12 residents with 12 reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R)7's Care Plan to reflect her implemented restorative services and goals. This deficient practice placed R7 at risk for impaired care due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of left-sided hemiparesis (weakness and paralysis on one side of the body), left-sided hemiplegia (paralysis of one side of the body), and left-hand contracture (abnormal permanent fixation of a joint or muscle). R7's Quarterly Minimum Data Set (MDS) completed 11/22/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to maintain Resident (R) 2's low air-loss mattress pump settings at the correct weight range. This placed R2 at increased risk for pressure ulcer development.

Inspectors wroteThe facility had a census of 104 residents. The sample included 23 residents with four residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when the facility failed to utilize wheelchair foot pedals while transporting Resident (R)18 and R22 around the facility. This deficient practice placed both residents at risk for preventable injuries and falls. Finding Included: - R18's Care Plan initiated 12/13/24 indicated he was at risk for falls related to his weakness, unsteadiness, poor safety awareness, and severe cognitive impairment. R22's Care Plan initiated 10/18/20 indicated she was at risk for falls related to poor gait/balance, muscle weakness, and severe cognitive impairment. On 02/26/24 at 07:20 AM R22 sat in her wheelchair in the hallway in front of the elevator. [...]

Inspectors wroteThe facility identified a census of 37 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure a pulse was assessed and documented consistently for Resident (R) 4's carvedilol (medication used to treat high blood pressure) for hypertension (HTN-elevated blood pressure) to monitor for efficacy and adverse effects. This placed R4 at increased risk for unnecessary medication administration and possible adverse side effects.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management before starting Resident (R)14's Seroquel (antipsychotic- class of medications used to treat mental disorder characterized by a gross impairment in reality testing). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings Included: [...]

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with two residents reviewed for dementia care. Based on record review and interviews, the facility failed to ensure staff provided person-centered care and services as related to dementia for Resident (R) 192. As a result, staff's inappropriate response to dementia-related behaviors resulted in a broken wrist for R192.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents. Based on observation, record review and interview, the facility failed to ensure the catheter bag of resident (R)39 was kept off the floor. The facility failed ensure that clean laundry was covered while being delivered to resident rooms and clean laundry was kept off the floor. These deficient practices placed the residents at risk for increased infection and transmission of communicable disease.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with one resident reviewed for death. Based on record review, and interviews, the facility failed to complete a baseline care plan for R42, which placed her at risk of impaired cares related to unidentified or uncommunicated care needs.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with one resident reviewed for hospice and end of life. Based on observation, record review, and interviews, the facility failed to revise the care plan with the correct hospice company for Resident (R) 20, which placed her at risk of delayed services for end of life comfort.

Inspectors wroteThe facility reported a census of 44 residents. The sample included 15 residents with 15 reviewed for quality of life. Based on observation, record review, and interviews, the facility failed to ensure all staff, across all shifts, honored Resident (R)14's preferences, requests and choices to ensure R14's quality of life. This deficient practice placed R14 at risk for decreased psychosocial wellbeing. Findings Included: [...]

Inspectors wroteThe facility identified a census of 44 residents. The sample included 15 residents with one resident reviewed for bowel and bladder maintenance Based on observation, record review and interview, the facility failed to ensure Resident (R) 39's indwelling catheter (a soft hollow tube inserted into the urethra or bladder) urine collection bag was stored off the floor, and was hung lower than bladder level. This deficient practice placed R39 at increased risk for infection, urinary retention, and other catheter related complications.

Inspectors wroteThe facility reported a census of 44 residents. The sample included 15 residents with one reviewed for nutrition and hydration . Based on observation, record review, and interviews, the facility failed to promote adequate hydration and nutrition when staff failed ensure accessible drinking water within reach for Resident (R)12. This deficient practice placed R12 at risk for altered hydration. Findings Included: - The Medical Diagnosis section within R12's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), muscle weakness, unsteadiness on feet, and history of falling. [...]