Claridge House Nursing and Rehabilitation Center

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure 1) proper temperatures of the foods stored in the 2 South Unit Floor Pantry Refrigerator and 1 North Unit Floor Pantry Refrigerator on the resident's units and 2) ensure kitchen staff were wearing a beard restraint. This has the potential to affect 54 residents out of 55 residents who eat orally residing on 2 South unit and to affect 44 out of 58 residents who eat orally residing on the 1 North unit at the time of the survey.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the refrigerators in the 2 South Unit Floor Pantry and 1 North Unit Floor Pantry used to store resident's food were working properly. This has the potential to affect 54 residents out of 55 residents who eat orally residing on 2 South unit and to affect 44 out of 58 residents who eat orally residing on the 1 North unit at the time of the survey.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a safe environment free from accidents hazards in four (Room # 231, room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]) out of fifty nine rooms on the second floor and for two (Resident #10 and Resident #153) out of thirty five sampled residents; as evidenced by 1) Personal hygiene products and medication found in residents' room unsecured 2) Resident #153 observed lying in bed with bilateral siderails upright with only left side rail padded. 2) Scissors observed on the table near Resident #10's bed and 3) A can of bug spray observed on the back shelf behind Resident #10's bed. There were 225 residents residing at the facility during the time of the survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for two residents (Resident #5 and Resident #211) with tracheostomies out of 11 residents receiving oxygen therapy. As evidenced by Resident #5 and Resident # 211 oxygen concentrator flow rates were not set at the prescribed rate.

Inspectors wroteBased on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate an effective plan of action was implemented to correct identified quality deficiencies in the problem area related to repeated deficient practice for F812- Food Procurement. Store/Prepare/Serve Sanitary. F867- QAPI/QAA Improvement Activities. F908- Essential Equipment, Safe Operating Condition. These repeated deficient practices have the potential to affect any of the 225 residents residing in the facility at the time of the survey. Record review of the facility's survey history revealed, during a recertification conducted on August 19, 2024, through August 22, 2024, the facility. was cited F812- Food Procurement, Store/Prepare/Serve Sanitary as the facility failed to ensure food was prepared under sanitary conditions. [...]

Inspectors wroteBased on observations, records reviewed and interviews, the facility failed to provide adequate supervision to ensure residents' safety for one out of 3 sampled residents (Resident #1). As evidenced by, on 03/30/2025 Resident #1 left the facility undetected at approximately 12:45 PM, boarded a city bus and was found 8 hours later by law enforcement. The resident was located 5.2 miles away from the facility. The areas where the facility and where the resident was located are in high traffic areas and there were cross streets which could lead to the increased risk of the resident being hit by an automobile, falling, or being assaulted and/or being robbed based on his vulnerability and cognitive impairment. According to website, Accuweather.com on 03/30/2025 the temperature ranged between 72 degrees Fahrenheit (F) to 86 degrees (F) with scattered showers. [...]

Inspectors wroteBased on observations, record review and interviews, the facility's administration failed to ensure effective systems were in place to provide adequate supervision for one out of three sampled residents (Resident #1). As evidenced by, on 03/30/2025 Resident #1 left the facility undetected at approximately 12:45 PM, boarded a city bus and was found 8 hours later by law enforcement. The resident was located 5.2 miles away from the facility. The facility and the area that the resident was located are both in high traffic areas with cross streets which could lead to the increased risk of the resident being hit by an automobile, falling, or being assaulted and/or being robbed based on his vulnerability and cognitive impairment. According to website, Accuweather.com on 03/30/2025 the temperature ranged between 72 degrees Fahrenheit (F) to 86 degrees (F) with scattered showers. [...]

Inspectors wroteBased on observations records reviewed and interviews, the facility's staff failed to address respiratory emergencies in a timely manner for two (Resident # 5 and Resident #6) out of three residents sampled residents; as evidenced by Resident #5 and Resident # 6 were noted in respiratory distress and the nurses failed to implement interventions in a timely manner.

Inspectors wroteBased on observations, reviews and interviews, the facility's staff failed to notify Resident #3's family /representative and physician of a change in condition for one out of three residents sampled as evidenced by Resident #3 who is at high risk for aspiration was observed vomiting and displaying signs of respiratory distress and on that specific date the facility staff did not notify the physician and the family of the changes in her condition. There were two hundred and ten residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement measures to prevent aspiration for one (Resident #3) out of three residents with percutaneous endoscopic gastrostomy (PEG) tube at risk for aspiration as evidenced by Resident # 3 was observed with vomit draining from her mouth and the Registered Nurses failed to implement interventions in a timely manner; and failed to implement interventions to prevent PEG tube dislodgement for two (Resident #6 and Resident # 7) out of three residents sampled as evidenced by Resident #6 was noted with his unsecured PEG tube line resting above his hand and Resident #7's tube feeding line was observed wrapped around the privacy curtain that was wrapped around the metal pole that had the feeding infusing and hanging loosely on the inner section of the wheelchair's wheel (Photo evidence). [...]

Inspectors wroteBased on observations, records reviewed and interviews, the facility failed to secure medications and ensure the resident (Resident #6) received all of the crushed medications mixed with water during medication administration observation for one out of one resident (Resident #6) as evidenced by, Staff A, Registered Nurse (RN) left Resident #6's medications unattended and failed to ensure the resident received the full amount of each medication via PEG (Percutaneous Endoscopic Gastrostomy/also known as G-tube). There were 27 Residents residing in the facility with PEG tubes. Medication observation on 01/23/2025 at 08:09 AM, Staff A, RN was observed administering medications to Resident # 6 via PEG. Staff A, RN entered the resident's room with crushed medications Tylenol 325 milligrams (mg.) 2 tablets and Eliquis Oral Tablet 2.5 mg 1 tablet separately mixed with water in cups and. [...]

Inspectors wroteBased on observations, interviews and record reviewed during this survey's investigations it has been determined that the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F 761 Label/Store Drugs and Biologicals, F693 Tube Feeding Management and F867 QAPI-QAA Improvement Activities. These repeated deficiencies have the potential to affect all residents residing in the facility.

Inspectors wroteBased on observations records reviewed and interviews the facility's staff failed to implement infection prevention control precautions as evidenced by staff failed to follow Enhanced Barrier Precautions during Tracheostomy care for one out of two residents with tracheostomy in the facility.

Inspectors wroteBased on observations, record review and interview the facility failed to ensure food was prepared under sanitary conditions as evidenced by failure to maintain equipment in the kitchen in a clean sanitary manner. This has the potential to affect one hundred and eighty-nine out of two hundred and seventeen residents who eat orally residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a convection oven and stove used to prepare food for residents were in good repair and clean. This has the potential to affect one hundred and eighty-nine out of two hundred and seventeen residents who eat orally residing in the facility at the time of the survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to accommodate a resident's choice for food preferences for one resident (Resident number 63) out of two residents reviewed for choices and preferences. There were a total of 217 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, record review and interview facility failed to implement the plan of care for one resident (Resident #75) out of five sampled as evidenced by no communication form filled out by nursing staff prior to dialysis. The findings Included: On 8/21/24 at 9:15 AM Resident #75 was observed in the Dialysis room. The Dialysis Home Program supervisor, Registered Nurse (RN) stated the floor nurse did not fill out a dialysis communication form for today but gave a verbal report to the Dialysis Patient Care Technician (PCT). On 8/21/24 at 9:18 AM dialysis PCT reported a verbal report was received from the nurse. Review of the demographic sheet for Resident#75 revealed an admission date of 2/9/22 and a readmission date of 9/3/23 with diagnosis that included: End Stage Renal Disease (ESRD), Dependence on Renal Dialysis. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the facility's protocols and policies and procedures were followed for Enteral Feeding for four residents (Residents #37, #89, #157 and #194) out of four residents observed for tube feedings. As evidenced by incorrect dates and missing start times observed on enteral supplements, water bag flushes and incorrect date on an Enteral Feeding syringe. The findings Included: Resident #37 During observation on 08/19/24 at 09:01 AM Resident #37's enteral feeding Glucerna noted running at 70 milliliter per hour (ml/hr.), automatic water flush 50 ml/hr., enteral feeding supplement dated 08/18/2024 with no start time (photo available). Review of the medical records for Resident #37 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: [...]

Inspectors wroteBased on observations, interviews, and record review facility failed to store and label medications properly in three medication carts out four sampled as evidenced by one expired eye drop on First floor south front medication cart, one unrefrigerated medication on second floor south back medication cart and one controlled substance count sheet not matching bingo card on the first floor north back medication cart. There were 232 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F 656 Develop/Implement Comprehensive Care Plan, F 761 Label/Store Drugs and Biologicals, and F 812 Food Procurement, Store/Prepare/Serve-Sanitary,. These repeated deficiencies have the potential to affect the 217 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observations record review and interview, the facility failed to ensure the laundry room is maintained in a safe clean/sanitary manner, as evidenced by washing machines noted soiled and dust laden; wasp nests on ceiling, rusted exhaust fans and floors in disrepair and failed to follow safety and infection control protocol for one out of four Biohazard rooms as evidenced by the the first floor North Biohazard room was not secured.

Inspectors wroteBased on record review and interviews, the facility failed to ensure medical records were complete and accurate with all information related to the care and services for one resident (Resident#1) out of nine sampled residents in accordance with accepted professional standard of practices as evidenced by no follow up documentation following an order for a wound care consult for Resident # 1. There were 210 residents residing in the facility at time of this complaint survey

Inspectors wroteBased on interview and record review, the facility failed to acknowledge concerns voiced by one (Resident #1) out of one residents investigated for loss of personal items.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I for serious mental illness (MI) or intellectual disability (ID) was completed at the time of admission for two residents (Resident # 145, Resident # 153) out of four residents investigated. This deficiency had the potential to affect 213 residents residing in the facility at the time of the survey.

Inspectors wroteBased on Observation, Record Review and Interview, the facility failed to implement a comprehensive care plan for falls for one (Resident #101) out of 44 residents sampled. There were 213 residents residing in the facility at the time of this survey. The Findings Included: During Observation on 04/17/23 at 09:23 AM, Resident #101 was in bed awake, a floor mat was on one side of the bed, the other floor mat was at the foot of bed against the wall (photo available). On 04/18/23 at 09:26 AM, Resident #101 was out of the facility at a medical appointment. On 04/19/23 at 08:59 Resident #101 was in bed awake, bilateral floor mats were resting on the wall at the foot of the bed (photo available). On 04/20/23 at 08:25 AM Resident #101 was observed in bed awake, bilateral floor mats were against the wall at the foot of the bed, a black stool was by the right side of the bed. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide a safe environment free of accident hazards for one (Resident #101) out of 44 residents sampled, as evidenced by bilateral floor mats not on the floor beside the resident's bed while the resident was in bed. There were 213 residents residing in the facility at the time of this survey. The Findings Included: During Observation on 04/17/23 at 09:23 AM, Resident #101 was in bed awake, a floor mat was on one side of the bed, the other floor mat was at the foot of bed against the wall (photo available). On 04/18/23 at 09:26 AM, Resident #101 was out of the facility at a medical appointment. On 04/19/23 at 08:59 Resident #101 was in bed awake, bilateral floor mats were resting on the wall at the foot of the bed (photo available). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to change the oxygen tubing weekly as required for three (3) Residents (#23, #70, #462) and follow the physician's order for oxygen therapy as prescribed for two (2) Residents (#145, #187) out of four (4) sampled residents. This had the potential to affect the 38 residents receiving respiratory therapy in the facility at the time of the survey. The Findings Included: 1. During observation on [DATE] at 09:17 AM, Resident #23 was observed in bed oxygen (02) running at 2.0 liters per minute (LPM) via nasal canula (NC), no dates observed on 02 tubing, Intravenous pole at bedside, nebulizer at bed side in a bag dated [DATE] (photo available). [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure pharmaceutical procedures were followed during and after medication administration for two (Resident #54, #89) out of six (6) residents sampled. There were 213 residents residing in the facility at the time of the survey. The Findings Included: 1. During medication observation on 4/18/2023 at 8:40AM with Licensed Practical Nurse (Staff G) poured 10 milliliters (ML) of Vitamin C Liquid in a medication cup and placed it on a foam tray for medication administration. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper temperatures of the foods stored in the 1 North Unit Floor Pantry Refrigerator. The refrigerator did not contain a thermometer in the refrigerator and the freezer. This has the potential to affect forty six residents out of fifty six residents who eat orally residing on 1 North wing.

Inspectors wroteBased on record review and interview, the facility failed to ensure the arbitration agreements presented to three residents (Resident number 165, Resident number 120 and Resident number 210) out of three residents reviewed provided for the selection of a venue convenient to both parties.

Inspectors wroteBased on observations, interview and record review, the facility failed to demonstrate an effective plans of action were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F602 Free from Misappropriation/Exploitation related to the facility failed to prevent misappropriation of funds for Resident #611, 316, 62, 315, 314, 313, and F755 Pharmacy Service/Procedures/Pharmacist/Records related to the facility failed to follow pharmacy procedures for Resident # 54, #89. These deficiencies have the potential to affect 213 residents residing in the facility at the time of survey.