Clearview

Inspectors wroteBased on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible for 1 or 6 residents (R9) reviewed for falls. R9 had a fall from bed, sustaining fractures (fx.) of left clavicle (collar bone) and left ribs 3-6, when CNA J (Certified Nursing Assistant) rolled R9 away from CNA J while performing cares. The facility did not have contemporaneous evidence CNA J, an agency CNA, received education to prevent future incidents from occurring. Evidenced by: The facility's Fall Prevention and Management policy, dated 2/28/25, states, in part: .Definitions Fall: The Centers for Medicare and Medicaid Services (CMS) defines a fall as an unintentional change in position that results in someone landing on the ground or a lower surface. Procedure .6. Responding to a fall .o. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 or 16 residents (R9) reviewed for change of condition. R9 went to the hospital for evaluation following a fall from bed. R9 sustained fractures (fx) of left clavicle (collar bone) and left ribs 3-6 and nursing assessments were not performed on return to the facility. Evidenced by:The facility's Fall Prevention and Management policy, dated 2/28/25, states, in part: .Definitions Fall: The Centers for Medicare and Medicaid Services (CMS) defines a fall as an unintentional change in position that results in someone landing on the ground or a lower surface. Procedure .6. Responding to a fall .l. Follow up assessments of the resident will be completed no less than the next 3 consecutive shifts. m. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident maintains acceptable parameters of nutritional status and is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 of 16 residents (R2) reviewed for nutrition. R2 was not weighed weekly for four weeks from time of admission and did not have a reweight when there was a loss of 9.8 pounds one month after admission. A nutritional supplement was ordered for R2 and was not routinely documented. As evidenced by: The facility's Nutritional Assessment and Care Planning policy, dated 3/20/23, states, in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident's environment remained free of accident hazards and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (R) reviewed for accidents (R14). Facility staff did not ensure R14's reclining chair remote was out of her reach per R14's care plan. R14 lifted the chair without staff present and fell resulting in a fracture. Evidenced by: The facility's Policy and Procedure entitled Fall Prevention and Management with a last reviewed date of 4/11/23 documents, in part: .Each resident be reviewed on admission, quarterly and with major change of condition for the potential fall risks, and preventative interventions taken when necessary. [...]

Inspectors wroteBased on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 52 residents. The staff line lists contain signs/symptoms (s/sx) such as something I ate, sick, ill, cold sx. They are not specific. The staff line lists were missing some Date last Symptom occurred dates. The facility's COVID summary not complete or accurate. This is evidenced by: The facility policy entitled Nursing Services/Infection Control: Infections: Reporting, Interventions, and Surveillance, dated 2/10/24, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a significant change in condition. This occurred for 1 of 17 residents (R46) reviewed for change in condition. R46 had a change in condition on 5/5, 5/26, and 6/10/24 that was not reported to R46's provider timely. This is evidenced by: The facility policy, entitled Physician Notification/Change in Condition dated 1/22/2024, states, in part: Policy: .A change in condition is when there is: .2. A significant change in the resident's physical, mental or psychological status (that is a deterioration in health, mental or psychological status in either life-threatening conditions or clinical complications. 3. A need to alter treatment significantly (that is. [...]

Inspectors wroteBased on interview and record review the facility did not ensure prompt resolution of all grievances for 2 of 14 residents (R47 and R32) reviewed for grievances out of a total sample of 17 residents. R47 voiced a grievance/concern to staff and did not receive any follow up on her voiced grievance/concern. R32 voiced a grievance/concern to staff and did not receive any feedback or a resolution to her concern/grievance. Evidenced by: Facility policy, entitled Grievance Policy and Procedure, effective date of 12/11/23, includes, in part: . staff are to ensure the prompt resolution of all grievances regarding the resident's rights. Any person is able to freely voice having a concern or problem with any matter concerning their rights including those with respect to care and treatment . the behavior of staff and other residents, and other concerns regarding their long-term care facility stay. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that lab values were monitored according to professional standards of practice for one resident (R8) out of 17 reviewed for professional standards of care. Specifically, the facility failed to properly identify and notify staff of one resident's lab value that differs from the accepted therapeutic range, which has the potential to cause R8 to experience adverse effects from not properly holding or administering the medication. R8 was recommended an INR (international normalized ratio, assesses how fast blood clots) therapeutic range from 1.5 to 2, which was not made readily available to nursing staff to review prior to holding or administering medication.

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not ensure 2 Residents (R)(R209 and R30) of 2 residents reviewed for respiratory care received care consistent with professional standards of practice. R209 and R30's respiratory care equipment was not sanitized and stored in a manner to maintain infection control standards.