Clifton Rehabilitation Nursing Center

Inspectors wroteBased on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #2), who were alert, oriented, and able to make their needs known, the Facility failed to ensure both residents were treated in a dignified and respectful manner when Certified Nurse Aide (CNA) #1 was witnessed by other staff members engaging in a verbal confrontation with both residents, during which CNA #1 became increasingly angry, raised his/her voice, spoke disrespectfully to Resident #1, and while questioning Resident #2, CNA #1 was heard using profane language.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to maintain a water management program to prevent the growth of Legionella (bacteria that can cause legionellosis (illness caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and other opportunistic waterborne pathogens.

Inspectors wroteBased on documentation review and interview, the facility failed to act promptly and demonstrate their response to concerns brought forth by the Resident Council.

Inspectors wroteBased on record review, interview, observation, and policy review, the facility failed for four Residents (#78, #29, #74, and #1), out of 26 sampled residents, to develop and implement individualized resident-centered care plans to meet the residents' needs. Specifically, the facility failed: 1. For Resident #78, to ensure a care plan was developed for the Resident's treatment of insomnia using an as needed (PRN) psychotropic medication; 2. For Resident #29, to implement fall care plan interventions, specifically to ensure the call light was wrapped with bright colored tape for better visibility and to ensure the anti-slip material to prevent the Resident from sliding off the wheelchair was in place; 3. For Resident #74, to implement fall care plan interventions, specifically to ensure the anti-slip material to prevent the Resident from sliding off the chair was in place; and 4. [...]

Inspectors wroteBased on resident and staff interviews, observation, and meal test tray results on two of three units, the facility failed to prepare and serve meals in a manner that conserved flavor, were palatable, and served at safe and appetizing temperatures.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products, and maintain safe and clean equipment in three of three nourishment kitchenettes.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to follow infection control practices including: 1. Ensuring staff performed hand hygiene in between resident care and with glove changes during the medication pass; and 2. Ensuring staff disinfected blood glucose monitoring equipment per policy.

Inspectors wroteBased on interviews, review of grievance documentation, and policy review, the facility failed to formulate grievances and failed to ensure the prompt resolution of grievances for the following: 1. Concerns brought forward by Resident #121 and their Family Member regarding long call light wait times and response from staff; and 2. Concerns brought forward by Resident #86 and their Family Member regarding missing items.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for three Residents (#4, #221, #32), out of a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #4, to ensure oxygen tubing was changed and stored in a plastic bag when not in use per facility policy; 2. For Resident #221, to store the Resident's Bilevel positive airway pressure (BiPAP) respiratory tubing and nasal pillow in a sanitary way when not in use by the Resident to prevent potential contamination by germs and environmental debris; and 3. For Resident #32, to ensure oxygen tubing was changed and stored in a plastic bag when not in use per facility policy.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure one Resident (#78), out of 26 sampled residents, had a documented rationale and appropriate monitoring in place for the ongoing, as needed (PRN) use of a psychotropic medication.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed: 1. For Resident #8, to ensure the morning medications were administered under direct supervision and not left at the bedside; 2. For Resident #106, to ensure Saline 0.65% Nasal Spray (for dryness) was stored in the medication cart and not left at the bedside; and 3. For Resident #112, to ensure Fluticasone Propionate Nasal Spray (for allergies) was stored in the mediation cart and not left at the bedside.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure that food is stored, prepared, and distributed in accordance with professional standards. Specifically, the facility failed to: 1.) Ensure that food was stored, prepared, and distributed under sanitary conditions; 2.) Ensure staff restrained their hair and changed their gloves/wash their hands when the gloves became contaminated while working in the kitchen; 3.) Ensure the concentration of the sanitizer in the third sink (of the three-bay sink) was at the correct concentration to sanitize pots and pans and reduce potential pathogens; and 4.) Ensure 3 of 3 kitchenette/refrigerators were maintained in a sanitary manner to store food and fluid.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to have an effective policy which addressed the reheating of residents' food brought in from home in accordance with professional standards to ensure food safety. Specifically, the facility failed to provide a thermometer and adequate reheating instructions to reheat residents' food brought in from home to an internal temperature of 165 degrees Fahrenheit (F) to prevent potential foodborne illnesses.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access on 2 out of 3 units.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure staff obtained timely dental services to replace a missing lower denture for one Resident (#71), out of 29 total sampled residents, resulting in a delay of eight months. Specifically, the facility failed to: 1. Consult the denture service provider regarding missing lower denture when first identified as missing, resulting in a four-month (March to July) delay in requesting an initial dental exam; 2. Follow up with dental service provider regarding prior approval/consent for replacement of denture from July to November resulting in an additional delay of four months; and 3. Notify family representative of dental services provided.

Inspectors wroteBased on observation, staff and resident interviews, and review of food temperature logs, the facility failed to ensure that food and drink are palatable, attractive, and served at a safe and appetizing temperature for 2 out of 3 units.

Inspectors wroteBased on Facility Assessment review and staff interviews, the facility failed to identify resources based on the resident population to determine the necessary care, support services, and educational resources needed to care for residents. Specifically, the facility failed to address the use of agency staff and the education and resources needed for the continued use of agency staff to fill licensed nurse staff positions.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff reported bruises of unknown origin to the Department of Public Health (DPH) within the required timeframe for one Resident (#103), out of a total sample of 29 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two Residents (#93 and #105), out of a total sample of 29 residents. Specifically, the facility failed: 1. For Resident #93, to develop a comprehensive care plan integrating hospice services into the facility care plan; and 2. For Resident #105, to develop a comprehensive care plan to address chronic urinary tract infections (UTIs).

Inspectors wroteBased on record review and interview, the facility failed to ensure staff followed professional standards of practice for not following physician's orders for one Resident (#59), out of 29 total sampled residents. Specifically, the facility failed to: 1. Provide the supplemental bolus of nutritional support through the gastrostomy tube (G-tube, an opening into the stomach for delivery of nutrition and hydration) within the physician ordered parameters; 2. Provide the physician ordered water flushing of the g-tube consistently; and 3. Accurately monitor the daily fluid intake and output (I&O) every shift indefinitely as ordered by the physician.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to: 1. Ensure adequate supervision and safety interventions were developed and consistently implemented to maintain safety to prevent additional falls; and 2. Follow the falls policy for documentation and assessments of falls for two Residents (#105, #69), out of a total sample of 29 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure that each resident receives a comprehensive nutrition assessment upon admission for three Residents (#236, #122 and #106), from a total sample of 29 residents. Specifically, the dietitian failed to follow the facility policy and complete a comprehensive nutrition assessment for each new admission to determine if the resident was at nutritional risk and provide nutrition interventions when appropriate.

Inspectors wroteBased on interviews, record reviews, and policy review, the facility failed to ensure professional standards were followed for one Resident (#88), out of a total sample of 29 residents. Specifically, the facility failed to: 1. Ensure physician's orders were in place for dialysis; 2. Ensure ongoing communication and collaboration with the dialysis facility by completing the communication sheets; 3. Inform the Dialysis Center of a positive laboratory result for clostridium difficile colitis (C. Diff) (Bacteria that causes diarrhea and inflammation of the colon); and 4. Inform the Dialysis Center of two new physician prescribed medications to treat the C. Diff.

Inspectors wroteBased on interview and education review, the facility failed to ensure the nursing staff received appropriate competencies and skill sets necessary for the care and treatment of residents. Specifically, the facility failed to ensure agency staff were provided education on facility specific emergency procedures.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the physician and/or nurse practitioner (NP) was notified of laboratory results which fell out of the clinical range for one Resident (#88), out of a total sample of 29 residents. Specifically, the delay in notification resulted in a three day delay in the Resident receiving treatment for clostridium difficile colitis (C. Diff) infection. Resident #88 was admitted to the facility in September 2022 with diagnoses of severe kidney disease, end stage renal disease, dependent on renal dialysis, and diabetes. Review of the Minimum Data Set (MD'S) assessment, dated 9/28/22, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the Resident had intact cognition. The MDS also indicated the Resident received dialysis. [...]

Inspectors wroteBased on observations, interviews, medical record review, and policy review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections in the facility for one Resident (#88), out of a total sample of 29 residents. Specifically, the facility failed to: 1.) Ensure that healthcare personnel perform hand hygiene, and don (put on) and doff (take off) the appropriate personal protective equipment (PPE) prior to entering a resident's room and while providing high contact care to a Resident on Contact Precautions for an active Clostridium difficile (C. diff) infection; 2.) Ensure that healthcare personnel perform hand hygiene per facility policy during meal pass for a Resident on Contact Precautions for an active Clostridium difficile (C. diff) infection; [...]

Inspectors wroteBased on record review, policy review and interview, the facility failed to implement their Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics for one Resident (#236), from a total sample of 29 residents. Specifically, the facility failed to complete Antibiotic Surveillance Tracking Forms (Line Listings), which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program.