Clinton Rehabilitation and Nursing Center

Inspectors wroteBased on record review, and interviews conducted during the recertification and abbreviated survey (Case #2790264) the facility did not ensure that residents were free from accidents and hazards for the facility and two (Residents # 72 and #75) of six residents reviewed. Specifically, (a) the facility did not provide therapeutic diets to prevent choking and aspiration, (b) Resident #72's care plan was not followed resulting in injury, and (c) the facility did not provide adequate monitoring to keep Resident #75 from suffering from frequent falls.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification and abbreviated survey (Case #2790264), the facility did not ensure that residents were free from abuse and misappropriation for one (Resident #s 15) of 23 residents reviewed for abuse prevention. Specifically for Resident #15, the facility failed to protect the resident from having their debit card used by staff for personal reasons.

Inspectors wroteBased on observation, record review, and interview during a survey, the facility failed to ensure residents received complete activities of daily living care by failing to provide oral care for three of four residents observed during activities of daily living care.(Resident #5. 27, #28 and #72 reviewed) This deficient practice had the potential to adversely affect residents' oral hygiene, comfort, nutritional status, and overall health. Specifically, for Resident #5, hygiene assistance was not provided for the resident over consecutive days.

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00369226), the facility did not ensure the resident's right to be free from abuse for 1 (Resident # 1) of 3 residents reviewed for abuse. Specifically, Resident #1 was not protected from verbal and physical abuse when Certified Nurse Aide #1 was witnessed by Activity Aide #1 and Licensed Practical Nurse #1 forcefully grabbing Resident #1's arm and being verbally aggressive. This is evidenced by: The facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, last revised on 10/20/2022 documented, it was essential for facilities to prohibit and prevent abuse, neglect, exploitation of residents. The facility would have systems in place to encourage and support reporting of suspected abuse. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00369226), the facility did not ensure that all alleged violations involving abuse were reported immediately, or no later than 2 hours after the allegation was made. If the events that caused the allegation involved abuse, they needed to be reported to the Administrator of the facility and to the State Survey Agency for 1 (Resident #1) of 3 residents reviewed. Specifically, an allegation of physical and verbal abuse was observed by staff on 01/16/2025 at approximately 11:00 AM. The allegation was reported to the New York State Department of Health on 01/17/2025 at 8:13 AM. This is evidenced by: The facility Policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, revised 10/2022 documented the following: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00369226), the facility did not ensure the resident's right to be free from further potential abuse, neglect, exploitation, or mistreatment while an investigation was in progress for 1 (Resident #1) of 3 residents reviewed for abuse and neglect. Specifically, Certified Nurse Aide #1 was not removed immediately from resident's care when there was an allegation of physical and verbal abuse to prevent further abuse from occurring. Certified Nurse Aide #1 was allowed to work until the end of their shift. This is evidenced by: The facility Policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, revised 10/2022 documented the following: [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality for 1 (Resident # 12) of 1 residents reviewed for dignity. Specifically, for Resident #12, the facility did not ensure the resident's suprapubic catheter urine drainage bag was not easily visible from the entrance room doorway. This was evidenced by: Resident #12 Resident #12 was admitted to the facility with diagnoses of anoxic brain damage, hypertension, and myocardial infarction. [...]

Inspectors wroteBased on record review and interview during a recertification and an abbreviated survey (Case # NY00310417), the facility did not ensure the resident representative was notified of a change in condition that required a change in the residents' plan of care, medication, or treatment regimen for 1 (Resident #39) of 2 residents reviewed for Resident/Patient/Client Rights Family/Resident Notification Issues. Specifically, for Resident #39, the facility did not ensure the resident representative was notified when the physician ordered an x-ray of the right foot to rule out osteomyelitis (inflammation of bone or bone marrow, usually due to infection) and when Morphine Sulfate (Concentrate) Solution 20 MG/ML, give 0.25 ml (5mg) by mouth as needed for pain, one dose per 24-hours to pre-medicate before right heel dressing change was ordered. This was evidenced by: [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey (Case # NY00273613 and NY00291813), the facility did not ensure all alleged violations of abuse, neglect, or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency for 2 (Residents #2 and 42) of 2 residents reviewed. Specifically, for Resident #2, the facility investigated staff reported bruising on the resident on 2/24/2022. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey and an abbreviated survey (Case #NY00310417) dated 7/17/2023 through 7/21/2023, the facility did not ensure the facility developed and implemented a comprehensive person-centered care plan for each resident for 3 (Resident #'s 9, 12, and 39) of 14 residents reviewed for Comprehensive Care Plans (CCP). [...]

Inspectors wroteBased on record review and interviews during the recertification survey and abbreviated survey (Case #NY00276602), the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #28) of 4 residents reviewed for accident hazards. Specifically for Resident #28, the facility did not provide adequate supervision to prevent accidents. This was evidenced by: Resident #28 Resident #28 was admitted to the facility with the diagnoses of Alzheimer's disease, ocular laceration and rupture with prolapse or loss of intraocular tissue and type 2 diabetes mellitus. The Minimum Data Set (MDS-an assessment tool) dated 5/28/21 documented resident was sometimes understood, could sometimes understand others and was severely cognitively impaired. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure the attending physician documented in the resident's medical record that identified irregularities had been reviewed and what, if any, action had been taken to address them and the facility did not ensure the facility must develop and maintain policies and procedures for the monthly drug regimen review that included, but were not limited to, time frames for the different steps in the process for 1 (Resident # 9) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #9, the facility did not ensure irregularities identified in the consultant pharmacy review, dated 01/11/2023, were reviewed within 60 days of receipt, per facility policy. [...]

Inspectors wroteBased on observation, record review and interview during a recertification survey the facility did not ensure comprehensive person-centered care plans were developed and implemented for each resident that included measurable observations and time frames to meet a resident's medical, nursing, mental and psychosocial needs for 5 (Residents #'s 5, 50, 52, 54, and #59) of 17 residents reviewed. [...]

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey on 5/24/2021, the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements related to F656; Development and Implementation of Comprehensive Care Plans, and F686; Treatment and Services to prevent/heal Pressure Ulcers. Specifically, the facility did not ensure that the approved Plan of Correction (POC) for F Tag 656 Development and Implementation of Comprehensive Care Plans, and F Tag 686 Treatment and services to prevent/heal Pressure Ulcers cited during the Recertification Survey completed on 2/28/2019 were implemented. This is evidenced by: [...]

Inspectors wroteBased on observation, interview and record review during a recertification survey, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infection for 2 (Unit A & C) of 2 units. Specifically, the facility did not ensure that contaminated items were not placed back into the clean multi-resident treatment cart that is used to provide treaments to residents' on both the A and C Units and did not ensure staff removed their gloves and perform hand hygiene between caring for the residents' and their environment. This is evidenced by: The Center for Disease Control (CDC) guidance titled Hand Hygiene Guidance, documented clinical indications for hand hygiene in healthcare settings are: [...]

Inspectors wroteBased on medical record review and staff interview during the recertification survey, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination. Specifically, residents who received Medicare Part A services did not receive timely notification (2-day notification) of the termination of services with the Notice to Medicare Provider Non-coverage (NOMNC), form CMS-10123. This was evident for 2 (Resident #16 and #34) of 3 sampled residents reviewed for Beneficiary Protection Notification.

Inspectors wroteBased on record review and interviews during a recertification survey the facility did not ensure that allegations of abuse, neglect, exploitation, or mistreatment had evidence that all alleged violations were thoroughly investigated for one (Resident #52) of 2 residents reviewed for abuse. Specifically, for Resident #52, the facility did not ensure the resident's allegation that a staff member was swearing and shouting at them and swearing and shouting at other residents was thoroughly investigated. This is evidenced by: [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not ensure, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 (Resident #12) of 2 residents reviewed. Specifically, for Resident #12, who has cognitive impairment, the facility did not ensure the resident was consistently provided ongoing and appropriate activities based on the resident's abilities. This was evidenced by: A request was made to the Administrator on 5/28/2021 for the facility Policy & Procedure titled Activities. The requested policy and procedure was not provided. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice for 1 (Resident #52) of 2 residents reviewed for pressure ulcers. Specifically, for Resident #52, the facility did not ensure the resident received weekly pressure ulcer evaluations for over a six week time period, did not ensure wound care was provided per professional standards of practice and did not ensure a Comprehensive Care Plan (CCP) was developed to prevent pressure ulcers and promote wound healing. This is evidenced by: Resident #52: Resident #52 was re-admitted to the facility with diagnoses of chronic obstructive pulmonary disease, peripheral vascular disease and type 2 diabetes. [...]

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for one (Residents #52) of one (1) resident reviewed. Specifically, for Resident #52, the facility did not a ensure Resident #52 was provided with a physician ordered positive airway pressure device at bedtime to treat sleep apnea and did not ensure Resident #52 received oxygen via nasal canula per MD orders. This is evidenced by: Resident #52: This resident was re-admitted to the facility with diagnoses of obstructive sleep apnea, chronic obstructive pulmonary disease, chronic heart failure, and heart disease. The Minimum Data Set (MDS-an assessment tool) dated 4/19/2021, documented the resident required oxygen therapy. [...]

Inspectors wroteBased on record review, and interviews during the recertification survey, the facility did not ensure training was provided to their staff on dementia management and resident abuse prevention. Specifically, the facility did not ensure staff were provided with training on dementia management and abuse prevention, such as understanding that expressions or indications of distress of residents with dementia are often attempts to communicate an unmet need, discomfort or thoughts that they can no longer articulate with words. However, the behaviors may be perceived as challenging to staff and could increase the risk for resident abuse and neglect. This was evidenced by: [...]

Inspectors wroteBased on observation, record review and interview during a recertification survey the facility did not ensure mechanisms for documenting and communicating the resident's choices regarding Advance Directives was made to the interdisciplinary team and to staff responsible for the resident's care and did not ensure comprehensive care plans were developed to address advance directives for eleven (11) (Residents #'s 27, 73, 175, 176, 26, 44, 45, 62, 29, 42, and #43) of eleven (11) residents reviewed. Specifically, for Resident #'s 175 and 44, the facility did not ensure the residents' wishes were communicated to the residents' direct care staff and physician after the residents completed a MOLST form that changed their code status from a full code to a Do Not Resuscitate (DNR). [...]

Inspectors wroteBased on record review and interview conducted during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for 8 (Residents #9, 14, 26, 30, 55, 63, and 47) of 23 residents reviewed. Specifically, for Residents #9 and 47 the psychotropic drug use care plans were not resident specific, and for Residents #'s 26, 45, and #63 there was no care plan to address the use of an anticoagulant, for Resident #30, the care plan intervention to monitor for edema and notify the physician was not implemented, for Resident #'s 14 and 55, the physician was not notified of weight loss per care plan instructions. This was evidenced by: Resident #47: [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure menus meet the nutritional needs of residents in accordance with established national guidelines, are updated periodically, and are reviewed and revised by the facilities dietitian for nutritional adequacy. Specifically, the facility did not ensure the resident's diet orders were in accordance with the diet manual, did not ensure the menu was updated periodically, and did not ensure the dietitian reviewed the menus for nutrition adequacy. This is evidenced by: Finding #1 The facility did not ensure the resident's diet orders were in accordance with the diet manual. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Food packages shall be in good condition and shall protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants; food temperature thermometers shall be calibrated; and floors and ceilings are to be kept clean. Specifically, cans of food were dented, food temperature thermometers were not in calibration, and ceiling vents and floors were not clean. This is evidenced as follows. The main kitchen was inspected on 02/24/2019 at 12:22 PM. One #10 can of fruit cocktail, found in the common stock, had two V-shaped dents in the hermetic seal. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure the policy regarding foods brought to residents by family and other visitors included information on the safe and sanitary storage, handling and consumption of food. Specifically, the facility did not provide information for family and other visitors on safe food handling practices or safe reheating of food that is brought in to residents. This is evidenced is as follows. The policy for foods brought in by visitors was reviewed on 02/24/2019. This policy does not include a process to ensure family and other visitors are provided information on safe food handling practices such as safe cooling/reheating processes, hot/cold holding temperatures, preventing cross contamination, and hand hygiene. [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure that written notification was provided to the resident and the resident's representative of the resident's transfer or discharge and the reasons for the move for 5 (Resident #'s 14, 18, 55, 72, and #176) of 5 residents reviewed for hospitalization. Specifically, the facility did not ensure there was documented evidence that the resident and resident's representative were notified in writing when the residents were admitted to a hospital from the facility. This is evidenced by: Resident #18: The resident was admitted to the facility on [DATE] with diagnoses including dementia, diabetes and depression. The Minimum Data Set (MDS) dated [DATE], assessed the resident could sometimes understand, sometimes be understood, and had severely impaired cognitive skills. [...]

Inspectors wroteBased on interviews and record review during a recertification survey, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 3 (Resident #'s 42, 44, and #45) of 7 residents reviewed for baseline care plans. Specifically, for Resident #'s 42, 44 and #45, the facility did not ensure a baseline care plan was developed within 48 hours of admission. This is evidenced by: Resident #42: The resident was admitted to the facility on [DATE] with the diagnoses of dementia, hypertension, and insomnia. The Minimum Data Set (MDS) dated [DATE] documented the resident had severely impaired cognition, could understand others, and could make herself understood. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice for 1 (Resident #61) of 1 resident reviewed for pressure ulcers. Specifically, for Resident #61, the facility did not ensure that consistent, weekly pressure ulcer evaluations were provided to the resident over a two-month period.

Inspectors wroteBased on observations, interviews, and record review during a recertification survey the facility did not ensure that a resident who entered the facility without limited range of motion (ROM) did not experience reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion was unavoidable; and §483.25(c)(2) A resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #62) of one resident reviewed for ROM. Specifically, for Resident #62, the facility did not ensure a blue hand roll was applied to the resident's left hand to help prevent contracture. This is evidenced by: Resident #62: [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure the resident environment remained free of chemical hazards for 1 (Resident #55) of 1 resident reviewed for accident hazards. Specifically, the facility did not ensure the resident's bedside table was free from housekeeping chemicals. This is evidenced by: Resident #55: The resident was admitted to the facility on [DATE] with type 2 diabetes, constipation, and gastro-esophageal reflux (GERD). A diagnosis list documented recurrent depressive disorders (6/29/16), anxiety disorder (5/26/16), aphasia (5/26/16), and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The Minimum Data Set (MDS) dated [DATE] documented the resident had severely impaired cognition, could sometimes understand others and could usually make herself understood. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutrition were maintained for 3 (Resident #'s 14, 43, and 55) of 6 residents reviewed for nutrition. Specifically, for Resident #'s 14 and 43, timely assessment and intervention did not occur when a resident experienced weight loss; for Resident #'s 14 and 55, the facility did not ensure that the physician was notified of weight loss as directed in the resident's care plan. This is evidenced by: The Policy and Procedure (P&P) titled Weighing Residents dated 2/2016 documented that the Dietetic Service Supervisor (DSS) was to review weights every Monday, document a progress note, and notify the Registered Nurse (RN) if a reweight or medical assessment was needed. [...]

Inspectors wroteBased on record review and interview during the recertification survey, the facility did not ensure a policy was developed for the monthly medication regimen review (MRR) that included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, the facility did not ensure that time frames were established for each step in the MRR process. This is evidenced by: The Policy for Medication Regimen Review with an effective date of 11/28/16 documented: 1. The Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the residents' health record. 2. [...]

Inspectors wroteBased on observation, interviews and record review during a recertification survey, the facility did not ensure the medication regime for one (1) resident (Resident #9) of five (5) reviewed for unnecessary medications was free from unnecessary medications. Specifically, for Resident #9, the facilty did not ensure that an as needed (PRN) anti-anxiety medication was adequately monitored for effectiveness, did not ensure the medication was administered for the physician ordered indication, did not ensure pharmacological interventions were utilized prior to administering the PRN anti-anxiety medication, and did not ensure documentation included the reason the medication was administered. Additionally, the facility did not ensure the resident's Psychotropic Care Plan included non-pharmacological interventions. This was evidenced by: Resident #9: [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure referral for dental services 1 (Resident #14) of 2 resident with loose-fitting dentures. Specifically, the facility did not ensure dental services were provided to a resident within 3 days for loose-fitting dentures. this is evidenced by: The Comprehensive Care Plan (CCP) titled Dental, last revised 10/16/17, documented interventions to monitor/document/report as needed for loose dentures, and mouth inspections at least weekly with changes reported to the nurse. Record review of the last 3 months did not include dental consults. A progress note dated 2/2/19, documented the resident became angry when teeth removed, though her dentures were not fitting or staying in place properly. [...]

Inspectors wroteBased on record review and interviews during the re-certification survey, the facility did not ensure food and nutrition staff had appropriate qualifications. Specifically, the facility did not ensure the food service director (FSD) designated to serve as the director of food and nutrition services received frequent scheduled consultations from the dietitian. This is evidenced by: The facility did not provide documentation of frequently scheduled consultations from the qualified dietitian to the FSD. During an interview on 2/25/19 at 2:39 PM, Food Service Supervisor #5 (FSS) stated she has been in her current position since 1999. She stated the consulting dietitian works 1-2 times a week in the evening, and they do not have regularly scheduled meetings at this time. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the dumpster was not closed or in good condition. This is evidenced as follows. The dumpster was inspected on 02/24/2019 at 12:22 PM. The top covers to the dumpster were open, four ¼-inch holes were found in the front side of the dumpster, and the front covers do not seat to the dumpster frame. Refuse was found inside the dumpster., The Cook/Manager stated in an interview conducted on 02/24/2019 at 1:07 PM, that she doesn ' t know who left the dumpster open, but all employees know to keep the dumpster closed; and the facility will call the dumpster vendor to replace the dumpster with one that does not have holes and covers that seat. 10 NYCRR 415.14(h)

Inspectors wroteBased on record review and interview the facility did not provide a complete Facility Assessment that documented a facility wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies during the recertification survey. Specifically, the facility did not ensure the facility assessment included an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's needs. This is evidenced by: On 02/27/19, the facility assessment was reviewed for Sufficient and Competent Nurse Staffing and did not include an evaluation of the staff needed to ensure a sufficient number of qualified staff were available to meet each resident's needs. [...]