Clifton Heights

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a sanitary and safe physical environment to help prevent the presence of pests within resident care areas. interviews and observations during survey revealed concerns with the presence of pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident requiring tracheotomy care received treatment and services in accordance with professional standards of practice, the resident's care plan, and facility policy. The failure had the potential to result in respiratory complications, infections, and compromised airway safety for 1 of 3 sampled residents, Resident(R)32.

Inspectors wroteBased on record review, interview, and review of the facility's policies, it was determined the facility failed to ensure an effective pain management regimen, based on a thorough assessment and a person-centered care plan, was implemented for 1 of 11 sampled residents receiving scheduled pain medications (Resident (R) 1). The facility failed to administer pain medication as ordered to R1, who had a history of chronic pain and required multiple daily doses of a potent opioid analgesic. The failure created ongoing, severe pain, and R1 also experienced withdrawal symptoms which he described as, The only way the pain was going away was if I died.

Inspectors wroteBased on record review, interview, and review of the facility's policies, it was determined the facility failed to ensure that 1 of 11 (Resident (R)1) sampled residents received diagnostic x-ray services in a timely manner, which created a delay in reporting any abnormal results to the physician and/or Nurse Practitioner, who had ordered the x-ray. After R1 sustained a fall, the facility failed to ensure that the resident received necessary follow-up, including implementation of physician orders for bilateral lower extremity (BLE) X-rays. R1 reported having severe leg pain and displayed swelling, changes in condition, and was eventually found to have a displaced tibia and fibula fracture that remained undiagnosed for approximately three days after his fall. R1 ultimately required surgery and 10 days of hospitalization in response.

Inspectors wroteBased on observation, interview, record review, review of the facility's policies and investigations, it was determined the facility failed to ensure the Comprehensive Care Plan was developed and/or implemented for four (4) of twenty-four (24) sampled residents (Residents #160, #310, #359, and #161). 1. Resident #160 expressed to staff his/her desire to be discharged home and he/she was anxious about his/her upcoming court hearing. The resident reported his/her concerns to staff on [DATE]; the week of [DATE], and on [DATE]; however, the facility failed to develop the resident's individualized person-centered care plan to include adequate supervision and monitoring. Therefore, on [DATE], the resident exited his/her window, climbed on a table with a chair stacked on top of the table and climbed across the facility's six (6) foot fence. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices necessary to prevent accidents for three (3) of twenty-four (24) sampled residents (Residents #160, #161, and #359). 1. On 04/22/2022 at approximately 12:30 AM, Resident #160 exited the facility through his/her window without staff's knowledge. The facility was unaware of Resident #160's whereabouts until a local shelter notified staff by telephone on 04/23/2022 at 11:15 AM of the resident's location. The resident was last seen on 04/21/2022 at 10:30 PM by Licensed Practical Nurse (LPN) #13, who checked his/her blood sugar and administered insulin as ordered at that time. [...]

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure a safe, clean, comfortable, and homelike environment. Observations of the linen storage revealed linens were not available to provide resident grooming, hygiene, and a comfortable bed for five (5) of twenty-four (24) sampled residents (Residents #6, #14, #25, #53 and #78). Observation of residents' pillows on their beds were not in good condition. The pillows were covered with a pillowcase, but the condition of the pillows exposed the resident to the potential unsanitary environment as the barrier on the pillowcase was no longer intact. The facility failed to ensure the residents were provided the necessary linens to provide for proper grooming, hygiene, and clean, sanitary, and comfortable beds.

Inspectors wroteBased on observation, and interview, it was determined the facility failed to store and serve food under sanitary conditions. Observations, during the lunch tray line on 06/06/2023, revealed the dish covers and bowls being used were wet. The Dietary Director was observed drying dishware with a paper towel. Further observation revealed the kitchen ingredient bins were not labeled or dated.

Inspectors wroteBased on observation, interview, record review, and review of facility policy review, it was determined the facility failed to ensure that residents' right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (1) of twenty-four (24) sampled residents (Resident #65). Observation of Resident #65's mobility was limited to his/her wheelchair. The resident was unable to get to the bathroom sink for personal hygiene due to his/her wheelchair not fitting through the bathroom door.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to report allegations of abuse within two (2) hours for one of twenty-four (24) sampled residents (Resident #34). On 05/05/2023, Certified Nurse Assistant (CNA) #18 heard an allegation from Resident #82 that Resident #312 groped Resident #34's genitals. However, CNA #18 stated she reported this to Registered Nurse (RN) #5 on 05/05/2023. However, staff failed to report this allegation to the Executive Director until four (4) days later on 05/09/2023.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure all assessments accurately reflected the resident's status for one (1) of twenty-four (24) sampled residents (Resident #359). Review of the admission Minimum Data Set (MDS) Assessment, dated 02/20/2023, revealed the resident was not assessed accurately for pressure. The MDS coded Resident #359 as having no pressure ulcer upon admission, however, it was documented by the Advanced Practice Nurse Practitioner (APRN) that the resident had a pressure wound present on his/her right buttock.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to promote the healing of existing pressure ulcers/injuries for one (1) of twenty-four (24) sampled residents (Resident #359). Resident #359's pressure wound was identified by the Advanced Practice Registered Nurse (APRN), on admission. However, the Nursing admission Assessment and the admission Minimum Data Set (MDS) failed to include this information. As a result, treatment for the wound was not provided for over a week following admission.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy it was determined the facility failed to ensure that each resident, who was incontinent of bladder and bowel on admission, received services and assistance to maintain continence for one (1) of twenty-four (24) sampled residents (Resident #65). Resident #65 had a neurogenic bladder and paraplegia. He/She had an indwelling suprapubic catheter and a colostomy. The resident utilized adult briefs because his/her catheter leaked. Resident #65 was unable to feel when he/she was wet due to his/her medical condition. Observation revealed the resident was found lying in a wet brief that had soaked through to his/her bedding.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure that residents received colostomy care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (1) of four (4) sampled residents out of a total sample of twenty-four (24) residents (Resident #65). Resident #65 had a colostomy and was unable to get out of bed without the use of a Hoyer ([NAME] of mechanical lift) lift. Resident #65 waited until noon for staff to assist with emptying his/her colostomy bag. Resident #65 was unable to obtain the supplies required for the care of his/her colostomy without the staff's assistance.

Inspectors wroteBased on observation, interview, and review of the facility's policy it was determined the facility failed to label and date tube feeding for one (1) of five (5) sampled residents, who received tube feedings (Resident #5). Observations on [DATE], [DATE] and [DATE] revealed the tube feeding was not labeled with the name, rate, formula, time, and date. Further observation revealed the IV (intravenous) flushes were not labeled or dated on [DATE].

Inspectors wroteBased on interview, facility policy review, and medical record review, it was determined the facility failed to protect the resident's right to dignity for one (1) of twenty-four (24) sampled residents (Resident #310). The facility failed to maintain the nasal cannula for supplemental oxygen in the correct position on the resident's face for Resident #310. Resident #310 became hypoxic and confused, smeared feces on his/her body, and walked in the hallways undressed while covered in feces. While in this hypoxic state, the resident stated a staff member was raping him/her; however, when the supplemental oxygen was put back on the resident, he/she recanted his/her statement.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure the storage of all drugs and biologicals in locked compartments. Observation of the medication pass revealed a Lantus insulin pen was left unattended on a medication cart. Further observations revealed the medication, Senna, was left in a cup, unattended, at the nursing station and accessible to residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to establish and maintain 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 for three (3) of twenty-four (24) sampled residents (Residents #24, #65, and #86). There was no Enhanced Barrier Precautions (EBP) sign on the door for Resident #24's and Resident #86's room. Resident #65's door did not have an EBP sign, and staff did not wear Personal Protective Equipment (PPE) while providing catheter care.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure dishes were sanitized prior to use. Observation revealed the dishwasher wash cycle water temperature was below the required temperature for sanitation per the manufacture's recommendation.

Inspectors wroteBased on observation and interview, it was determined the facility failed to ensure a clean, homelike environment for the residents on three (3) of four (4) halls, the West, North, and East Halls. Observations revealed windows in resident rooms and common areas were soiled with a cloudy, grayish haze, spider webs, and dried clumps of grass. In addition, the utility room across from the nurses' station, the medication room, and the ceiling fan in the nurses' station were soiled.

Inspectors wroteBased on observation, interview, and personnel file reviews, it was determined the facility failed to complete annual performance reviews for seven (7) of eight (8) Certified Nursing Assistants (CNA) files reviewed, CNA #3, #4, #5, #6, #7, #8, and #11.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to implement the care plan for one (1) of five (5) sampled residents, Resident #36. The resident was to have treatments administered to his/her pressure ulcer and observation revealed the nurse did not perform glove changes and hand hygiene during wound care to prevent possible complications, per the care plan.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined the facility failed to ensure a resident was notified of quarterly care plan meetings to allow for participation in care goals for one (1) of eighteen (18) sampled residents, Resident #24.

Inspectors wroteBased on interview, record review, and review of facility policy, it was determined the facility failed to ensure medical records were accurately documented to reflect the care and services provided to residents for two (2) of eighteen (18) sampled residents, Resident #28 and #32. Record review revealed missing documentation related to the residents' wound care.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure adequate infection control techniques during wound care for two (2) of five (5) sampled residents, Resident #28 and #36.

Inspectors wroteBased on interview, record review, facility policy review, and review of the sit to stand lift manual, it was determined the facility failed to maintain equipment safe for resident use on one (1) of four (4) halls, the North Hall. Observation and interview revealed a sit to stand lift did not function properly and was available for staff use. In addition, the facility failed to ensure the dishwasher was maintained per manufacturer recommendation. Observation of the dishwasher revealed it did not reach the required wash cycle temperature of 160 degrees Fahrenheit (F).