Clifton Springs Hospital and Clinic Extended Care

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey from 11/07/2024 to 11/15/2024, for one (Resident #93) of nine residents reviewed, the facility did not ensure that the medical team was notified in a timely manner following a significant medication error. Specifically, the medical team was not notified timely when a medication had not been administered according to physician's orders resulting in potentially serious side effects. This is evidenced by the following: The facility policy Event Reporting revised October 2023, documented the definition of an error was a mistake in process that was made, regardless of impact to the patient, that should not have been present and caused harm. Examples of errors includes medication variances. Any error, close calsl, or other safety event should be reported and appropriate follow-up services as necessary. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/15/2024, for three (Residents' #16, #43, and #86) of 23 residents reviewed, the facility did not develop and/or implement comprehensive person-centered care plans that included measurable goals and interventions to meet the residents' medical, nursing, and psychosocial needs as identified in their comprehensive assessments. Specifically, the comprehensive care plan for Resident #16 did not include goals or interventions related to their respiratory function and tracheostomy (a surgically created opening in the neck and into the windpipe to help with breathing and remove secretions). For Residents #43 and #86, the comprehensive care plan did not include measurable goals or interventions related to active skin impairments. This is evidenced by the following. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/15/2024, the facility did not ensure that services were provided to meet professional standards of quality for one (Resident #93) of two residents reviewed during medication administration pass. Specifically, Resident #93 had a medication signed off as administered but was omitted during the observed medication pass. Additionally, Resident #93 had multiple doses of a medication that had been signed off as administered, but were not administered, due to not being available, with no evidence that the medical team had been notified. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/15/2024, for one (Resident #16) of nine residents reviewed, the facility did not ensure each resident received adequate supervision to prevent accidents. Specifically, Resident #16 was identified to be a high risk for aspiration (accidental inhalation of food or drink into the airway) that required full supervision with meals and was observed not supervised at mealtime. This is evidenced by the following: The facility policy Aspiration Precautions/Dysphagia dated March 2024, included residents with dysphagia (difficulty swallowing) and/or at risk for aspiration are assessed and appropriate resident centered interventions are incorporated into the resident's care plan. [...]

Inspectors wroteBased on observations, interviews, and record reviews conducted during a Recertification Survey from 11/07/2024 to 11/15/2024, the facility did not ensure the daily nurse staffing information was consistently posted to include the daily resident census, the total number and actual hours worked by the licensed and certified nurses at the beginning of each shift on a daily basis, and that they were readily accessible to residents and visitors. Specifically, the nursing staff information was not posted in a readily accessible location for all residents and visitors, the information was not completed or updated for night shift and on weekends, and the information posted was not updated or consistently accurate. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey completed on 3/3/23, it was determined that for two of six residents reviewed for accidents, the facility did not ensure that the resident's environment remained as free of accident hazards as possible. Specifically, Resident #36 was not appropriately assessed, and care planned to have medications left at their bedside for self- administration and Resident # 28 was served and consumed a meal tray that contained an inaccurate diet consistency. This is evidenced by the following: 1. Resident #36 had diagnoses including end stage renal disease requiring dialysis, hypertension, diabetes, and depression. The Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #36 was cognitively intact. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey completed on 5/18/21, it was determined for one (Resident #31) of one resident reviewed the facility did not notify the resident of new treatment plans. Specifically, test results and treatment plans were not reviewed with the resident following a cardiology consult. This is evidenced by the following: Review of a facility policy, Notification of Changes in Resident Status, dated February 2018, included to notify residents, families and/or the resident representative, according to their authority, of changes in the resident's status and that the facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative (s) regardless of resident's competency when there is a need to alter treatment significantly. [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey completed on 5/19/21, it was determined for one (Resident #18) of one resident reviewed the facility did not review and revise the resident's care plan (with input from the resident or resident representative, to the extent possible), if necessary to meet the resident's needs. Specifically, Resident #18 complained to the facility that they required more assist with brushing their teeth than staff were providing, and the resident's care plan was not revised to meet the resident's needs. This is evidenced by the following: Resident #18 had diagnoses including gingivitis with advanced gum disease, dry mouth, and anxiety disorder. A Minimum Data Set Assessment, dated 5/8/21, revealed the resident was cognitively intact, required set up help for personal hygiene, and no rejections of cares. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey completed on 5/18/21, it was determined that for one (Resident #22) of three residents reviewed, the facility did not provide the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #22 did not receive nail care or shaving per their preferences. This is evidenced by the following: Resident #22 had diagnoses including vascular dementia without behavioral disturbance, a stroke and muscle weakness. The Minimum Data Set Assessment, dated 2/23/21, documented that Resident #22 was cognitively intact and required assistance of one person for grooming and personal hygiene. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, completed on 5/19/21, it was determined that for one of one resident (Resident #44) the facility did not provide care and services consistent with professional standards of care to meet the needs of a resident on dialysis. Specifically, the facility did not monitor the resident's fluid restriction os ordered and did not provide ongoing monitoring and care of the resident's vascular access. This is evidenced by the following: A facility policy, Hemodialysis Guidelines, dated April 2017, directs staff that upon the residents return from dialysis and at least daily, to feel lightly with fingertips over the fistula (a surgical graft used for dialysis) for a thrill (vibration) and auscultate (listen) for a bruit (swishing sound). Staff should document on the treatment sheet that both are present. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, completed on 5/18/21, it was determined for two of two residents, the facility did not ensure that the residents or resident's representatives were notified in writing of the reason for a transfer or discharge from the facility. Specifically, Resident #7 and Resident # 91 were transferred to the hospital and there was no documented evidence that the residents or their representatives received a copy of the written transfer notice. The facility policy Notice of Transfer, Discharge or Bed Hold, dated May 2018, included the nursing home must issue a valid discharge notice to the resident, and if known, to a family member or legal representative of the resident. For urgent transfers out of the facility: a copy of the notice of discharge form should be sent with the resident at the time of transfer/discharge. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey completed on 5/18/21, it was determined for two (Resident #7 and #91) of two residents reviewed, the facility did not ensure the residents or the resident's representatives were notified of the facility's bed hold policy per the regulations. Specifically, the residents were transferred to the hospital and there was no documented evidence that the residents or their representatives were notified of the facility's bed hold policy at the time of their hospitalizations. This is evidenced the following: The facility policy Notice of Transfer, Discharge or Bed Hold, dated May 2018, included the nursing home must issue a valid discharge notice to the resident, and if known, to a family member or legal representative of the resident. For urgent transfers out of the facility: [...]