Clifton Healthcare Center

Inspectors wroteBased on observation, staff interview, record review, and review of the facility policy, the facility failed to store foods in a sanitary manner and failed to maintain a clean and sanitary kitchen This had the potential to affect 135 of 137 residents who received food from the kitchen. The facility census was 137 residents.

Inspectors wroteBased on medical record review, staff interview, guardian interview, and review of the facility policy, the facility failed to obtain consent from resident guardians regarding treatment. This affected (Residents #28, #64, #121, and #138) of 27 residents reviewed for consent for treatment. The facility census was 137 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to document timely care conferences for residents. This affected four (Residents #79, #1, #15, and #135) of 27 residents sampled. The facility census was 137 residents:

Inspectors wroteBased on observation, staff interview, document review, and review of the facility policy, the facility failed to safely store chemicals on the secured unit. This had the potential to affect seven facility-identified independently mobile and cognitively impaired (Residents #16, #30, #48, #75, #79, #115, #130) who resided on the secured unit. The facility census was 137 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide nailcare for dependent residents. This affected two residents (#35 and #64) of three residents reviewed for activities of daily living (ADL) care. The facility census was 137 residents.

Inspectors wroteBased on medical record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure residents received care and services for management of contractures and decreased range of motion. This affected three (Residents #65, # 41 and #2) of three residents reviewed for range of motion services. The facility census was 137 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) for residents with orders for contact precautions. This affected two residents (Resident #77 and #131) of seven residents reviewed for infection control. The facility also failed to ensure staff practiced appropriate hand hygiene during incontinence care. This affected one resident (Resident #123) of seven residents reviewed for infection control. The facility census was 137 residents.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure residents had visual privacy in their bedroom. This affected two residents (Resident #15 and #147) of three residents reviewed for the physical environment. The facility census was 137 residents.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on personnel record review, review of criminal background check records, staff interview and review of the facility policy, the facility failed to complete background checks upon hire for new employees. This had the potential to affect all of the residents residing in the facility. The facility census was 137 residents.

Inspectors wroteBased on record review, observation, staff interviews, and policy review the facility failed to ensure physician orders were timely clarified to prevent a delay in medication administration. This affected one (#37) resident of the three residents reviewed for medication administration. The facility census was 140.

Inspectors wroteBased on interview and record review, the facility failed to submit complete and accurate staffing information for the Payroll-Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 137 residents in the facility. Findings Included: Review of the [NAME] PBJ staffing data report revealed the facility triggered for excessively low weekend staffing and a one star staffing rating for fiscal year quarter two of 2023. Interview with [NAME] President Analytics (VPA) #201 on 11/20/23 at 4:12 P.M. revealed the facility submitted the PBJ in the second quarter of 2023 and CMS has the wrong information. VPA #201 indicated the corporate team was working on the PBJ report and would resubmit it to CMS for the second quarter.

Inspectors wroteBased on record review, staff interviews, and review of facility policies, the facility failed to ensure a fall was thoroughly investigated, accurately documented, and fall interventions were implemented to prevent additional falls. This affected one (#04) of the nine residents reviewed for accident hazards. The facility also failed to ensure residents were supervised while smoking, failed to ensure residents smoked safely and failed to ensure residents were assessed for smoking. This affected four (#10, #95, #04, and #187) of the nine residents reviewed for accident hazards. The facility census was 137.

Inspectors wroteBased on observations, medical record review, and staff interview the facility failed to serve lunch in a family style manner. This affected one (#117) of the 37 residents observed during the lunch meal service. The facility census was 137.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident's advanced directives were accurately reflected in the clinical record. This affected one (#127) of the 32 residents reviewed for advanced directives. The facility census was 137.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed correctly to include a mental health diagnosis. This affected one (#74) of five residents reviewed for PASARR. The facility census was 137.

Inspectors wroteBased on record review and staff interview the facility failed to ensure care conferences were completed. This affected two (#117 and #29) of the 27 residents reviewed for care planning. The facility census was 137.

Inspectors wroteBased on observations, staff interview, medical record review and review of facility policy, the facility failed to ensure dependent residents were provided with effective grooming. This affected one (#86) of the four residents reviewed for the provision of activities of daily living (ADLs). The facility census was 137. Findings Included: Review of medical record for Resident #86 revealed an admission date 07/26/23. Diagnoses included chronic obstructive pulmonary disease (COPD), bipolar disorder, and malignant neoplasm of upper lobe left, secondary malignant neoplasm of brain. Review of the plan of care dated 07/28/23 revealed that Resident #86 had an ADLs self-care performance deficit related to signs and symptoms of involving musculoskeletal system, chronic pulmonary disease, migraines, fatigue, unsteadiness on feet, and poor motivation towards self-care. [...]

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected three (#95, #50 and #16) of five residents reviewed for unnecessary medications. The facility census was 137.

Inspectors wroteBased on record review, observation, staff interview and policy review, the facility failed to discard expired medications and failed to label multi dose medication with the expiration date. This affected one medication room and one medication cart. The census was 137.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure a resident's fall and use of feeding tube were accurately coded on the Minimum Data Set (MDS) assessment. This affected two (Resident #84 and Resident #91) of 27 residents reviewed for accuracy of assessments. The facility census was 137.

Inspectors wroteBased on record review, and staff interviews, the facility failed to accurately complete pre-admission screening and resident review (PASARR) for a newly admitted resident. This affected one (Resident #57) of four residents reviewed for PASARR. The facility census was 137.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's code status was accurately documented in the electronic record and a resident's fall with nursing assessment was documented in the medical record. This affected two (Resident #51 and Resident #61) of 33 residents reviewed for complete and accurate medical records. The resident census was 137.

Inspectors wroteBased on record review, observation, staff interview, and review of facility policy, the facility failed to perform hand hygiene between resident medication administrations and failed to follow infection control principles while preparing medications. This had the potential to affect four (Resident #72, #80, #127, #131) of seven residents observed for medication administration. The facility also failed to implement proper infection control measures for a central intravenous (IV) line for one (Resident #75) of two residents reviewed for dialysis. The census was 137.