Suites At Clermont Park Care Center, The

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure one (#38) of two residents reviewed for resident rights out of 35 sample residents received appropriate treatment and services consistent with his interests, assessments and plan of care. Specifically, the facility failed to ensure Resident #38 received his showers consistently with his preferences. Findings include: I. Resident #38A. Resident status Resident #38, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized orders (CPO), diagnoses included acute respiratory failure with hypoxia (low blood oxygen levels), urinary tract infection and muscle weakness. The 2/4/26 minimum data (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident required moderate assistance for showering and was dependent on staff for toileting, dressing, eating, hygiene and transfers. B. Resident representative interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection.Specifically, the facility failed to rinse and store nebulizers (a small machine that turns liquid medication into a mist that can be inhaled to treat lung conditions) masks and reservoirs properly. Findings includeI. Professional referenceThe Center for Disease (CDC) Guidelines for the Prevention of Nosocomial Pneumonia, dated September 2024, was retrieved on 2/19/26 from https://www.cdc.gov/mmwr/preview/mmwrhtml/00045365.htm. It read in pertinent part: Outbreaks related to the use of respiratory-therapy equipment have been associated with contaminated nebulizers. When the fluid in the reservoir of a nebulizer becomes contaminated with bacteria, the aerosol produced may contain high concentrations of bacteria that can be deposited deep in the patient's lower respiratory tract. Contaminated reservoirs of aerosol-producing devices (nebulizers) can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to provide a response, action and rationale to residents involved in group grievances. Specifically, the facility failed to follow up with residents' concerns regarding call light response times that were brought up by the resident council during regular meetings. Findings include: I. Facility policy The Grievance Management policy, which was undated, was provided by nurse consultant (NC) #2 on 1/10/24 at 6:02 p.m. It read in pertinent part: The community upholds and supports resident rights and seeks to address any alleged violation of such rights in a timely and effective manner. Any resident, resident representative or the resident advisory council had the right to voice grievances to the community without discrimination or reprisal or fear of discrimination or reprisal. A complaint or issue brought to the attention of the community by a resident or resident representative that is not resolved more informally and in a very timely manner (generally within three days) will be referred to the formal problem-resolution…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to maintain personal privacy during care for two (#36 and #4) of three residents reviewed for privacy of 41 sample residents. Specifically, the facility failed to: -Close Resident #36's bedroom door while she was assisted by staff with getting dressed after a shower; and, -Close Resident #4's bathroom and bedroom doors while she was assisted to the bathroom. Findings include: I. Facility policy The Resident Rights policy, implemented November 2022, was provided by the community executive director (ED) on 1/10/24 at 9:26 p.m. read in pertinent part: Residents have the right to be treated with respect and dignity. Residents have the right to privacy in treatment and caring for residents' personal needs. II. Resident #36 A. Resident status Resident #36, age over 65, was admitted on [DATE]. According to the January 2024 computerized physician order (CPO) diagnoses included Bell's Palsy (unexplained facial muscle weakness or paralysis) and neurocognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for two (#18 and #30) of four residents out of 41 sample residents reviewed for ADLs Specifically, the facility failed to provide: -Assistance with hydration for Resident #30 and Resident #18; -Restorative therapy for Resident #18; and, -Change Resident #18 care plan when her assistance level had changed. Findings include: I. Resident #18 A. Resident status Resident #18, age72, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included lateral sclerosis (muscle twitching and weakness), chronic kidney disease and osteoarthritis (degenerative joint disease). The 11/16/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for two (#9 and #20) out of 41 sample residents. Specifically, the facility failed to: -Provide supervision to Resident #9 while suspended in a Hoyer mechanical lift; and, -Prevent skin injuries to Resident #20 during care with staff. Findings include: I. Resident #9 A. Professional reference The Hoyer lift User Manual, written in 2014, read in pertinent: The Hoyer lift is intended for indoor use only and must be operated by a minimum of two people or carers. B. Resident status Resident #9, age over 65, was admitted on [DATE]. According to the January 2024 computerized physician order (CPO), diagnoses included acquired absence of left leg below the knee (leg amputation), age-related osteoporosis, polyosteoarthritis (cartilage degeneration), chronic pain, dementia, Parkinsonism (brain condition that caused slowed movements and stiffness) and encounter for palliative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure residents received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being for two (#3 and #43) of four residents reviewed for dementia care out of 41 sample residents. Specifically, the facility failed to ensure Resident #3 and Resident #43, who had dementia, were provided consistent specialized services and support with activities of daily living (ADLs) and a meaningful activity program. Findings include I. Facility policy The Rhythms Dementia Services policy, which was undated, was provided by nurse consultant (NC) #2 on 1/10/24 at 9:26 p.m. read in pertinent: Our Rhythms Dementia Philosophy and Program recognizes that dementia changes the way a person experiences the world around them. Our job is to create [NAME] where life is worth living. We are committed to honoring and supporting people wherever they are in the rhythm of their life. The majority of distress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on one of four medication carts. Specifically, the facility failed to: -Discard prepared and contaminated medication that had not been administered; and, -Maintain the temperature of opened food items on the medication cart. Findings include: I. Facility policy The Medication Storage policy, revised January 2023, was provided by the community executive director (ED) on 1/17/23 at 4:45 p.m. It read in pertinent part: Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. The Food and Supply Storage policy, revised January 2023, was provided by nurse consultant (NC) #1 on 1/10/24. It read in pertinent part: Cover, label and date unused portions and open packages. Store foods in their original packages. Food that must be opened must be stored in NSF (National Sanitation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews and staff interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious disease. Specifically, the facility failed to offer updated COVID-19 vaccinations and document consent or declination for vaccination for Residents #7 and #27. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Stay Up to Date with COVID -19 Vaccines/What You Need to Know, revised 11/16/23, retrieved on 1/16/24 from: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html, in pertinent part: CDC recommends the 2023-2024 updated COVID-19 vaccines: Pfizer-BioNTech, Moderna, or Novavax, to protect against serious illness from COVID-19. Everyone aged 5 years and older should get one dose of an updated COVID-19 vaccine to protect against serious illness from COVID-19. People who are moderately or severely immunocompromised may get additional doses of updated COVID-19…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to honor resident choices for three (#16, #17 and #26) of four reviewed for self-determination, out of 26 sampled residents. Specifically, the facility failed to ensure dependent Residents #16, #17 and #26 received showers consistently according to their preference. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy was requested by the nursing home administrator (NHA) and director of nursing (DON) on 9/15/22 at 12:45 p.m. The DON said the facility did not utilize an ADL policy, but instead utilized a standard of practice competency. The Standard of Practice Giving a Tub Bath/Shower Competency was provided by the NHA on 9/15/22 at 12:30 p.m. It read in pertinent part, Check POC (point of care) to see if assigned residents are due for tub bath/shower and level of assistance. Always consider the resident's preferences for bathing, including type, time, products, etc. -However, the competency did not include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews the facility failed to ensure two out of two medication refrigerators stored and secured drugs and biologicals in accordance with accepted professional principles. Specifically, the facility failed to: -Ensure multi-dose vials of Tuberculin were dated when first opened; -Ensure alcohol for drinking was not stored with medications; -Ensure food and medications were not stored together; and, -Ensure expired medications were removed from the medication rooms. Findings include: I. Professional reference According to the Tubersol package insert, retrieved on 9/19/22 from https://www.fda.gov/media/74866/download, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. II. Facility policy and procedure The Storage of Medications policy and procedure, dated 2007, was provided by the director of nursing (DON) on 9/14/22 at 12:35 p.m. It read in pertinent part, Medications and biologicals were stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#37) of four residents reviewed for hospice services out of 26 sample residents. Specifically, the facility failed to: -Have a written agreement to ensure for Residents #37, a written plan of care included both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility; and, -Ensure that the LTC facility staff provide orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents. Findings include: I. Resident #37 A. Resident status Resident #37, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), senile degeneration, reduced mobility, chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.