Clinton Place

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents' rights were protected related to meal service for 2 residents out of the 20 sampled residents, (Resident (R)70 and R81).

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to store medication in accordance with accepted standards of practice, which had the potential to affect 83 out of 83 facility residents.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect 20 of the facility's 83 residents.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure all bathrooms were equipped with call lights at each toilet that was accessible to residents who sustained a fall, and was lying on the floor.

Inspectors wroteBased on observation, record review, interviews, and facility policy review it was determined that the facility failed to provide quality of care related to skin impairment and Activities of Daily Living for one of 33 sampled residents. (Resident #45 (R45)). On 07/15/2023 at 12:44 AM, nursing observed small white insects approximately 3 cm [centimeters] in size what appeared to look like small worms, in creases of resident's wound beds on both lower extremities. The resident had a temp of 101.6 and was complaining of chills and sweats. Resident 45 was sent to the emergency room for evaluation. Additionally, staff documented on 06/01/2024 and 06/02/2024 the resident had white particles on her outer thigh area of BLE (bilateral extremities), in the resident abdominal folds, and inner creases of BLE. [...]

Inspectors wroteBased on observation, interviews, record review, and review of the facility's policy it was determined the facility failed to maintain an effective pest control program to ensure it was free of pests. All 81 residents had the potential to be affected. On 07/15/2023, 06/01/2024, and 06/02/2024, Resident (R) 45 was found to have maggots in her skin folds and bilateral lower extremity wound beds. Observation on 06/27/2024 at 1:42 PM revealed flies in R45's room with one fly on the resident's face and one fly on the left side of the resident's neck. Refer to F684.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored in accordance with professional standards for food service safety. Kitchen observation on 03/26/19, revealed ice build-up on a shelf below the fan and an area of the floor of the walk-in freezer. Review of the Census and Condition, dated 03/26/19, revealed sixty-five (65) of sixty-seven (67) residents received their food from the kitchen.

Inspectors wroteBased on interview, and record review, it was determined the facility failed to notify the representative of one (1) of twenty-three (23) sampled residents of a medication change (Resident #45). On 03/02/19, an order was written to discontinue Resident #45's Celexa; however, staff failed to notify Resident #45's representative.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for three (3) of twenty-three (23) sampled residents (Residents #5, #36, and #43). Resident #36 had a decline in activities of daily living (ADL's), bowel and bladder continence, cognition, and a significant weight loss from 10/28/18 to 01/24/19; Resident #43 had a decline in four (4) areas of ADL's; and, Resident #5 had an Improvement in three (3) areas of ADL's. However, further review of the residents' MDS assessments revealed a significant change in condition was not identified and a Significant Change MDS assessment was not completed per the RAI 3.0 Users Manual.

Inspectors wroteBased on interview, record review, and review of facility policy, it was determined the facility failed to develop a person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for three (3) of twenty-three (23) sampled residents, (Residents #36, #9, and #52). Record review revealed the facility failed to develop a person-centered, individualized activities of daily living care plan for Resident #36; a care plan to reflect the care of a resident with dementia for Resident #9; and a care plan for care of a resident with a Urinary Tract Infection for Resident #52.

Inspectors wroteBased on interview, record review, and facility policy review it was determined the facility failed to revise the care plan for one (1) of twenty-three (23) sampled residents (Resident #60). Resident #60 received hemodialysis three (3) times a week and had a physician order for staff to palpate for bruit and thrill in left arm every shift. However, the comprehensive care plan did not reflect the intervention and there was no documented evidence the assessment of the site was completed

Inspectors wroteBased on interview, record review, and review of the facility policy, it was determined the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for two (2) of twenty-three (23) sampled residents (Residents #36 and #42). Resident #36 and Resident #42 had a decline in bowel and bladder status; however, a bowel and bladder assessment was not completed nor was a bowel and bladder program put in place to attempt to restore the residents to his/her previous continent status or prevent further decline per facility policy.

Inspectors wroteBased on interview, record review and facility policy review, it was determined the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (2) of twenty-three (23) sampled residents (Residents #41 and #60). Resident #41 received dialysis on Tuesday, Thursday and Saturday and Resident #60 received dialysis on Monday's Wednesdays and Fridays; however, the facility failed to assess the residents' fistulas for thrill (a pulsing feeling), bruit (a whoosh), and signs and symptoms of infections per facility policy.

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined the facility failed to ensure drugs and biologicals used in the facility were dated/labeled in accordance with currently accepted professional principles. On 03/26/19, observation of one (2) of two (4) medications carts on Side Two hall and the Lighthouse Unit, revealed staff failed to date medications when opened per facility policy.