La Bella at Clifton

Inspectors wroteBased on interviews and record reviews the facility failed to protect one (R6) resident from verbal and physical abuse out of nine residents reviewed for abuse in a sample list of 12 residents. R6 was admitted to the facility on [DATE] and has the following medical diagnoses; Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Sepsis, Inflammatory Disorders of Scrotum, Abnormalities of Gait and Mobility, Unsteadiness on Feet, Cerebral Infarction, COPD, Muscle Wasting and Atrophy, Lack of Coordination, Type 2 Diabetes, GERD, Heart Failure, Major Depressive Disorder, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Tachycardia, HTN, Gout, Muscle Weakness, Malaise, Acquired Absence of Left Leg Above Knee and Nicotine Dependence. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a severely cognitively impaired resident (R16) did not exit the facility unnoticed (elopement), failed to implement post fall interventions (R6), and failed to thoroughly investigate a fall/injury (R7). R1 is three of four residents reviewed for elopement, and R6 and R7 are two of three residents reviewed for falls in the sample list of eight.

Inspectors wroteBased on interview and record review the facility failed to ensure a Minimum Data Set (MDS) accurately assessed for wandering for one of three residents (R1) reviewed for elopement in the sample list of eight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 74 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan to include residents smoking status. This failure affects one (R16) of seven residents reviewed for accidents in the sample list of 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the right to be free from physical abuse for three (R1, R2, &R3) of four residents reviewed for abuse from a sample list of four residents.

Inspectors wroteBased on interview and record review the facility failed to implement effective interventions to prevent abuse for three (R1, R2, R3) of four residents reviewed for abuse from a total sample list of four residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect a resident's (R1) right to be free from physical abuse by another resident (R2). This failure affects two (R1, R2) of seven residents reviewed for abuse in the sample list of 14. This failure resulted in R2 abusing R1, causing R1 to experience psychosocial harm as evidenced by crying and fear of R2.

Inspectors wroteBased on interview and record review the facility failed to timely report an allegation of resident to resident physical abuse to the administrator and to the state survey agency for two (R1, R2) of seven residents reviewed for abuse in the sample list of 14.

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to properly perform a mechanical lift transfer resulting in a fall, failed to document falls in the medical record, investigate falls and develop/implement post fall interventions for two (R2,R3) of three residents reviewed for falls in a sample list of 14. Findings Include: Facility Policy dated August 2024 documents that two nursing assistants are needed to safely move a resident with a full mechanical lift. This policy also documents that the full mechanical lift may be used for tasks that require, transferring a resident from bed to the chair, and lateral transfers. 1.) R3 Minimum Data Set from 2/12/2025 documents R3 has severe cognitive impairment with substantial/maximum assistance. R3's Nursing Note dated 4/1/25 at 8:38 AM R3 had a witnessed fall. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to identify triggers, develop a care plan and implement interventions and services to address a past history of abuse (R1). This failure affects three (R1, R2, R14) of seven residents reviewed for abuse in the sample list of 14.

Inspectors wroteBased on observation, interview and record review the facility failed to care plan, identify targeted behaviors and develop/implement personalized interventions to address dementia related behaviors (R2). This failure affects two (R1, R2) of seven residents reviewed for abuse in the sample list of 14.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician's orders and manufacturer's instructions for two (R9, R11) of nine residents reviewed for medication administration in the sample list of 14. This failure resulted in three medication errors out of 26 opportunities, an 11.5% medication error rate.

Inspectors wroteBased on observation, interview, and record the facility failed to ensure a wheelchair was in safe operating condition for one (R3) of three residents reviewed for falls on the sample list of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a plan of care to reduce resident intrusion of privacy and resulting in aggression. This failure has the potential to affect two residents (R1 and R2) out of three reviewed for allegations of abuse on the sample list of three.

Inspectors wroteBased on interview and record review, the facility failed to develop their abuse prevention policy to include a definition of abuse to include abuse facilitated or enabled by the use of technology. This failure has the potential to affect all seventy residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to sufficiently staff Certified Nursing Assistants (CNAs). This failure affects five of seven residents (R1, R2, R3, R5, R7) reviewed for staffing in the sample list of seven. This failure has the potential to affect all 71 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to sufficiently staff dietary support personnel resulting in delayed timeliness of meals for four of seven residents (R1, R2, R3, R4) reviewed for dietary services in the sample list of seven. This failure has the potential to affect all 71 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to maintain food ordering and supply to ensure the menus are followed and to log substitutes. This failure affects three of seven residents (R1, R2, R5) reviewed for dietary services in the sample list of seven and has the potential to affect all 71 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to sufficiently staff housekeepers to maintain a clean and homelike environment for five of seven residents (R1, R2, R5, R6, R7) reviewed for housekeeping in the sample list of seven.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure substitutes were available and failed to honor residents' food preferences for six of seven residents (R1, R2, R3, R5, R6, R7) reviewed for dietary services in the sample list of seven.

Inspectors wroteBased on interview and record review the facility repeatedly failed to provide showers as scheduled for three of three dependent residents (R2, R3, R4) reviewed for showers in the sample list of five.

Inspectors wroteBased upon observation, interview, and record review the facility failed to prevent the transmission of clostridium difficile (C-Diff) infections, failed to ensure shower rooms were disinfected to prevent the spread of infection, failed to obtain lab results, and failed to follow hand hygiene guidelines. This affected 8 (R1, R2, R7, R8, R9, R10, R11, R12) of 12 residents reviewed for infection with the potential to affect all 68 residents residing at facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to timely administer a resident's oral and intravenous antibiotic medication for an infected j-tube (jejunostomy tube) as prescribed to avoid a significant medication error. R2 received the first dose of IV antibiotics 10 days after it was ordered for the multi drug resistant organism in the J-tube site. This failure affects one of three residents (R2) reviewed for medications in the sample list of 12.

Inspectors wroteBased on interview and record review the facility failed to obtain informed consent prior to administering an antipsychotic medication to one of three residents (R5) reviewed for chemical restraints in the sample list of 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide showers to two of three dependent residents (R2, R3) reviewed for showers in the sample list of 12.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's opioid pain medication was administered as prescribed to avoid a potential lethal dosage for one of three residents (R1) reviewed for significant medication errors in the sample list of three. This failure resulted in R1 receiving a dose of Narcan (opioid reversal medication) and being transported by ambulance to the emergency room for evaluation.

Inspectors wroteBased on interview and record review, the facility failed to maintain and monitor adaptive devices to ensure proper functioning to prevent a fall for one of one resident (R53) reviewed for falls on the sample of 36. This failure resulted in R53's unsecured toilet seat riser sliding off the toilet when R53 was sitting and/or transferring onto the toilet, causing R53 to fall. R53 sustained a fractured finger and laceration requiring three sutures. Findings Include: R53's Fall Risk assessment dated [DATE] documents R53 is at risk for falls. R53's MDS (Minimum Data Set) dated 3/1/24 documents R53 has severe cognitive impairments. R53's Progress Notes document the following: 2/18/24 - CNA (Certified Nursing Assistant) heard R53 yelling. When CNA entered the room, R53 was sitting on the bathroom floor with dislodged toilet riser wedged between R53's torso and the toilet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 69 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess for the use of side rails, obtain consent for side rail use, and care plan side rail use for four (R7, R38, R41, R55) of four residents reviewed for side rails in the sample list of 36.

Inspectors wroteBased on interview and record review the facility failed to maintain resident influenza and pneumococcal vaccination information and offer pneumococcal vaccines for four (R31, R7, R14, R54) of five residents reviewed for immunizations in the sample list of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess side rails for risk of entrapment for four (R7, R38, R41, R55) of four residents reviewed for side rails in the sample list of 36.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete R15 and R54's comprehensive assessment. This failure affects two (R15, R54) of three residents reviewed for accuracy of assessments on the sample list of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement physician orders for laboratory results and withholding medication, and failed to assess, measure, and implement treatments for diabetic wounds for one (R31) of two residents reviewed for skin conditions in the sample list of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a wound assessment for a pressure ulcer, follow physician orders for wound treatments, and monitor dressing to ensure they were intact for two of two residents (R15, R69) reviewed for pressure ulcers on the sample list of 36. Findings Include: 1. R69's Progress Notes dated 4/13/24 documents R69 was admitted to the facility from the hospital and has a stage 2 (pressure) wound to the coccyx. R69's medical record did not contain any wound assessments until 4/19/24, 6 days after admission. This wound assessment documents a stage 2 pressure ulcer to the sacrum measuring 2 cm (centimeters) by 0.5 cm by 0.1 cm. R69's May 2024 Physician Orders document the following Sacral Wound Treatment: apply a non-bordered foam dressing, cutting a donut out over wound, and secure it with tape twice a week. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to initial and date oxygen, nebulizer, and humidification bottles, and failed to cover nebulizer for two (R41 and R70) of two residents reviewed for respiratory care on the sample list of 36. Findings Include: The facilities Oxygen and Respiratory Equipment-Changing/Cleaning Policy dated 3/2024 documents; Purpose: 1. Provide guidelines to employees for changing all disposable respiratory supplies. 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. 3. To minimize the risk of infection transmission. Procedure: 1. Handheld Nebulizer (HHN) and Mask, if applicable. A. The handheld nebulizer should be changed weekly and as needed (PRN). b. A clean plastic bag with zip loc or draw string, etc. [...]

Inspectors wroteBased on interview and record review the facility failed to identify and care plan specific targeted behaviors and nonpharmacological interventions, and complete psychotropic medication assessments for one (R31) of five residents reviewed for unnecessary medications in the sample list of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer insulin per manufacturer's instructions and facility policy. There were 3 medication errors out of 33 opportunities, resulting in a 9.09% medication error rate. This failure affects three (R16, R32, R1) of six residents reviewed for medication administration in the sample list of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure intravenous medications were accurately labeled for two (R22, R42) of six residents reviewed for medication administration in the sample list of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a mobility device within a resident's reach. This failure resulted R1 sustaining a fall, requiring hospitalization due to a Subdural Hemorrhage. The facility also failed to ensure a call light was within reach for R3, who has a history of falls. These failures affect two of three residents (R1 and R3) reviewed for falls on the sample list of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was properly secured during a vehicle transport while sitting in a wheelchair, failed to ensure a resident had a properly fitting wheelchair for safe positioning, failed to assess a resident with potential for injury after sliding off the wheelchair prior to moving them, and failed to immediately report the accident to facility administration for one of three residents (R14) reviewed for accident hazards on the sample list of 26. This failure resulted in R14 sliding forward, halfway falling out of the wheelchair and hitting R14's leg on the elevated van stoop/ledge and back of the driver's seat, resulting in a right sided fractured patella and femur, a suspected lateral clavicular fracture, and a suggested comminuted proximal fracture of the fibula. This failure resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to have the required members attend the Quality Assurance Performance Improvement (QAPI) meetings. This failure has the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote resident's dignity by failing to ensure staff did not stand over residents while providing feeding assistance and ensuring a resident's incontinence brief was not completely exposed in a public area for 2 of 18 residents (R8, R60) reviewed for dignity in the sample list of 26.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold policy to one of one resident (R49) reviewed for hospitalizations on the sample list of 26. Findings Include: R49's ongoing census documents R49 was hospitalized from [DATE] - 12/23/22. On 4/02/23 at 8:41 AM, R49 stated R49 got sick pretty quick a few months back and with all R49's breathing issues, the facility sent R49 to the hospital but that R49 never received any paperwork about saving the bed. R49 also stated R49 has had previous hospitalization and didn't receive any bed hold policy then either. R49's medical record does not contain a bed hold policy for R49's 12/19/22 - 12/23/22 hospitalization. [...]

Inspectors wroteBased on interview and record review, the facility failed to transmit a resident's Minimum Data Set (MDS) assessment within 14 days of the completion date for one (R63) resident reviewed for discharge MDS assessments on the sample list of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan to address pain and risk of pressure ulcers for one of 26 residents (R172) reviewed for care plans on the sample list of 26. Findings Include: R172's ongoing census documents R172 was admitted to the facility on [DATE]. On 4/02/23 at 8:56 AM, R172 was heard yelling out, ouch from behind doors. Upon entering room, V33 (Certified Nursing Assistant) was in R172's room repositioning R172 onto R172's left side. R172 was lying in bed on a regular mattress. R172 stated R172's right leg hurts when being moved due to a fall at home, but nothing is broken. R172 explained the facility gives R172 pain medicine but they don't always help and it really only hurts when I move though so I stay in bed a lot. I did get up into the chair yesterday and it felt good though. [...]

Inspectors wroteBased on interview and record review the facility failed to revise and update a resident's care plan for one of two residents (R32) reviewed for care plans in a sample list of 26.

Inspectors wroteBased on observation, interview and record review, the facility provided hot packs for pain relief without a physician order for one of one resident (R172) reviewed for pain on the sample list of 26. Findings Include: On 4/02/23 at 8:56 AM, R172 was heard yelling out, ouch from behind doors. Upon entering R172's room, V33 (Certified Nursing Assistant/CNA) was in the room repositioning R172 onto R172's left side. R172 stated R172's right leg hurts when being moved due to a fall at home. R172 stated the facility gives R172 pain medications but they don't always help. Two used disposable Hot Packs were sitting in R172's windowsill. At 8:58 AM, V33 stated V33 had been putting hot packs on R172's groin area for the past three days for the pain as well as R172 is getting pain medications. R172's March and April 2023 Physician Orders do not contain an order for hot packs to the groin. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a pressure ulcer treatment was administered according to physician orders for one of three residents (R14) reviewed for pressure ulcers on the sample list of 26. Findings Include: R14's Wound Physician Notes dated 3/30/23 documents R14 has full thickness wounds to the left proximal medial foot and left medial first toe, full thickness caused by a cast on the opposite leg/foot rubbing on the foot. The left proximal medial wound measures 1.5 cm (centimeters) by 1 cm by 0 cm and the left medial first toe wound measures 1 cm by 1 cm by 0 cm. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received the correct oxygen flow rate as ordered by the physician for one of one resident (R11) reviewed for oxygen administration in the sample list of 26. Findings Include: The facility's Oxygen Concentrator policy with a revised date of January 2013 documents, Purpose. To provide Oxygen for therapeutic use by utilizing a concentrator that converts ambient air to a high concentration level of oxygen. It is commonly used to provide oxygen therapy. Procedure. 1. Verify and understand the physician's order. 2. Know the flow rate and duration of use. 9. Adjust the flow meter control knob to the flow setting prescribed by the physician. The graduated line of the meter should be aligned with the center of the floating ball. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the use of an as needed (PRN) antipsychotic medication was not administered beyond 14 days without clinical justification and evaluation for its use and failed to provide clinically pertinent explanation for concomitant use of two antipsychotic medications for one of five residents (R11) reviewed for unnecessary medications in the sample list of 26.