Nazareth Home Clifton

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure all drugs used in the facility were labeled and stored in accordance with professional standards. Observations during survey revealed medication in 2 separate unlabeled and unattended medication cups on top of 1 of 7 medication carts and 1 of 4 treatment carts was unlocked and unattended, with no staff in sight of the treatment cart

Inspectors wroteBased on interview, record review and review of the facility's policy, it was determined the facility failed to protect resident rights for one (1) out of twelve (12) sampled residents. (Resident #7) On [DATE] CNA #2 reported Licensed Practical Nurse (LPN) #5 took Resident #7's cell phone from the Resident's hands against the Resident wishes. Resident #7 expired on [DATE].

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure an environment that was free from abuse involving one (1) of fourteen (14) sampled residents (Resident #9). On 12/04/2021, Resident #2 placed his/her arm around the neck of Resident #9 and stated, I'll get him/her out of here, I'll choke him/her.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to protect residents from Misappropriation of property for three (3) of twelve (12) sampled Residents. (R#3, R#8, R#10). a.) On [DATE] Resident #8's family member dropped off gifts and twenty (20) dollars in lottery tickets, the lottery tickets were missing. b.) On [DATE] Resident #10's cell phone was missing. c.) On [DATE] Resident #8 alleged thirty (30) dollars was missing from his/her room. d.) On [DATE] Resident #3 had three (3) rings missing from his/her room. e.) On [DATE] Resident #10's family reported he/she had three (3) rings missing from his/her hands when he/she expired.

Inspectors wroteBased on interview and record review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included a focused problem with measurable objectives to meet the resident's mental and psychosocial needs which are identified in the comprehensive assessment for two (2) of fourteen (14) sampled residents (Resident #9 and Resident #12). a.) On 12/04/2021, the facility failed to implement and update Resident #9's Comprehensive Care Plan after resident-to-resident altercation. b.) Staff failed to implement Resident #12's Care Plan by providing feeding assistance, and obtaining daily weights as ordered to maintain nutritional status and prevent weight loss.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure residents received appropriate supervision for one (1) of fourteen (14) sampled residents (Resident #13). On 10/12/2021 Resident #13 was left unsupervised in the shower with no staff assistance for Activities of Daily Living (ADLs).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents identified at nutritional risk, with physician orders related to feeding assistance, were provided the needed assistance to ensure nutritional status was maintained for one (1) of fourteen (14) sampled residents, Resident #12. Staff failed to provide Resident #12 with feeding assistance, and failed to obtain daily weights as ordered to maintain nutritional status and prevent weight loss.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to establish an infection control system to monitor for Legionnaire's Disease. Additionally, the facility failed to provide signage to notify visitors to the facility of the presence of Coronovirus-19 (COVID) in the facility. The facility census was one hundred and one (101). Observation, on 11/22/2023, revealed a sign posted at the front entrance to the facility notifying visitors if they were feeling sick or had signs or symptoms of illness not to enter the facility. However, there was no signage to notify visitors of the presence of active COVID inside the facility.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to store, prepare, and serve food in a sanitary manner. Observations revealed frozen raw chicken thawing in the sinks in the soiled dish room and the refrigerators contained expired milk, available for use. In addition, staff did not maintain hand hygiene while serving meals.

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to maintain resident dignity for one (1) of twenty-eight (28) sampled residents, Resident #8. Observation of Resident #8's room revealed a white board with written notations regarding the resident's care, which was visible to visitors and other residents from the hallway outside the resident's room.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to keep resident care information confidential for one (1) of twenty-eight (28) sampled residents, Resident #8. Resident #8 had a white board on the wall of his/her room that faced the hallway. The white board contained care information for Activity of Daily Living (ADL) needs and was visible to other residents and visitors from the hallway.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to maintain a home like environment for two (2) of twenty-eight (28) sampled residents, Resident #14 and #23. Observation revealed Resident #14's room had missing wood under the window on the back wall of the room with a large hole visible. In addition, the facility failed to maintain a comfortable water temperature for bathing for Resident #23.

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to complete accurate Minimum Data Set (MDS) assessments for two (2) of twenty-eight (28) sampled residents, Resident #22 and #54. Resident #22 had a diagnosis of Pulmonary Hypertension; however, the MDS assessments completed on 02/05/18, 07/17/18, and 09/10/18, did not include the diagnosis. Resident #54 had a pacemaker; however, the MDS assessments completed 03/05/18 and 10/05/18 did not identify the resident had a pacemaker.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to develop a care plan for two (2) of twenty-eight (28) sampled residents, Resident #22 and #54. Resident #22 had a diagnosis of Pulmonary Hypertension; however, care plan review revealed the plan did not reflect the diagnosis of Pulmonary Hypertension. Resident #54 had a cardiac pacemaker; however, care plan review revealed the facility did not develop a care plan for the pacemaker.

Inspectors wroteBased on observation, interview, Material Safety Data Sheet review, and facility policy review, it was determined the facility failed to provide a safe environment for residents on one (1) of four (4) nursing units, the 500 Unit. Observations revealed a clean utility room door was unlocked, accessible to residents, and contained multiple hazardous chemicals. In addition, Resident #80 had a can of ant spray in his/her possession that he/she used to spray the baseboards and window on a routine basis.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to ensure controlled medications were maintained in separately locked, permanently affixed compartments in two (2) of four (4) medications rooms, on the 300 Unit and 500 Unit. Observation of the medication rooms revealed controlled medication stored on the shelf of the doors in the refrigerators.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to maintain an effective infection control program related to hand hygiene on one (1) of four (4) units. Observation revealed the nurse failed to perform hand hygiene between residents during medication pass on the 300 Unit.