Clifton Springs Hospital and Clinic Extended Care

Based on interviews and record review conducted during the Recertification Survey from 11/07/2024 to 11/15/2024, for one (Resident #93) of nine residents reviewed, the facility did not ensure that the medical team was notified in a timely manner following a significant medication error. Specifically, the medical team was not notified timely when a medication had not been administered according to physician's orders resulting in potentially serious side effects. This is evidenced by the following: The facility policy Event Reporting revised October 2023, documented the definition of an error was a mistake in process that was made, regardless of impact to the patient, that should not have been present and caused harm. Examples of errors includes medication variances. Any error, close calsl, or other safety event should be reported and appropriate follow-up services as necessary. Resident #93 had diagnosis including hypertension (high blood pressure), transient ischemic attack (mini stroke), and myocardial infarction (heart attack). The Minimum Data Set Resident Assessment, dated…

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, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/15/2024, for three (Residents' #16, #43, and #86) of 23 residents reviewed, the facility did not develop and/or implement comprehensive person-centered care plans that included measurable goals and interventions to meet the residents' medical, nursing, and psychosocial needs as identified in their comprehensive assessments. Specifically, the comprehensive care plan for Resident #16 did not include goals or interventions related to their respiratory function and tracheostomy (a surgically created opening in the neck and into the windpipe to help with breathing and remove secretions). For Residents #43 and #86, the comprehensive care plan did not include measurable goals or interventions related to active skin impairments. This is evidenced by the following. Review of the facility policy Comprehensive Person-Centered Care Planning Process, dated March 2024, included a comprehensive person-centered interdisciplinary care plan will be developed for each individual…

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, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/15/2024, the facility did not ensure that services were provided to meet professional standards of quality for one (Resident #93) of two residents reviewed during medication administration pass. Specifically, Resident #93 had a medication signed off as administered but was omitted during the observed medication pass. Additionally, Resident #93 had multiple doses of a medication that had been signed off as administered, but were not administered, due to not being available, with no evidence that the medical team had been notified. This is evidenced by the following: The facility policy Medication Administration revised February 2020, included the six rights of medication administration as the right patient, right medication, right dose, right time, right route, and right documentation. Resident #93 had diagnoses that included stroke, diabetes, and constipation. The Minimum Data Set Resident Assessment, dated 09/03/2024, revealed Resident #93 was cognitively intact.…

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, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/15/2024, for one (Resident #16) of nine residents reviewed, the facility did not ensure each resident received adequate supervision to prevent accidents. Specifically, Resident #16 was identified to be a high risk for aspiration (accidental inhalation of food or drink into the airway) that required full supervision with meals and was observed not supervised at mealtime. This is evidenced by the following: The facility policy Aspiration Precautions/Dysphagia dated March 2024, included residents with dysphagia (difficulty swallowing) and/or at risk for aspiration are assessed and appropriate resident centered interventions are incorporated into the resident's care plan. Enteral feed/ventilator/tracheostomy residents must be on aspiration precautions and the care plan team will determine what mealtime supervision the resident requires, considering any recommendations from the speech therapist, and the registered nurse will add the mealtime supervision requirement to…

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 conducted during the Recertification Survey completed on 3/3/23, it was determined that for two of six residents reviewed for accidents, the facility did not ensure that the resident's environment remained as free of accident hazards as possible. Specifically, Resident #36 was not appropriately assessed, and care planned to have medications left at their bedside for self- administration and Resident # 28 was served and consumed a meal tray that contained an inaccurate diet consistency. This is evidenced by the following: 1.Resident #36 had diagnoses including end stage renal disease requiring dialysis, hypertension, diabetes, and depression. The Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #36 was cognitively intact. Record Review on 3/1/23 of Resident #36's Comprehensive Care Plan (CCP) revealed no information, including goals, interventions, or assessments for safe self-administration of medications or for medications left at the…

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 interviews and record reviews conducted during the Recertification Survey completed on 5/18/21, it was determined for one (Resident #31) of one resident reviewed the facility did not notify the resident of new treatment plans. Specifically, test results and treatment plans were not reviewed with the resident following a cardiology consult. This is evidenced by the following: Review of a facility policy, Notification of Changes in Resident Status, dated February 2018, included to notify residents, families and/or the resident representative, according to their authority, of changes in the resident's status and that the facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative (s) regardless of resident's competency when there is a need to alter treatment significantly. A need to alter treatment significantly means a need to stop a form of treatment or commence a new form of treatment to deal with a problem. The notification will be documented in the interdisciplinary…

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, interviews and record review conducted during the Recertification Survey completed on 5/19/21, it was determined for one (Resident #18) of one resident reviewed the facility did not review and revise the resident's care plan (with input from the resident or resident representative, to the extent possible), if necessary to meet the resident's needs. Specifically, Resident #18 complained to the facility that they required more assist with brushing their teeth than staff were providing, and the resident's care plan was not revised to meet the resident's needs. This is evidenced by the following: Resident #18 had diagnoses including gingivitis with advanced gum disease, dry mouth, and anxiety disorder. A Minimum Data Set Assessment, dated 5/8/21, revealed the resident was cognitively intact, required set up help for personal hygiene, and no rejections of cares. The resident's current Comprehensive Care Plan and the Interdisciplinary Care Card (both direct daily care), for oral care included that the resident had their own teeth, was independent with brushing after…

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, interviews and record reviews conducted during the Recertification Survey completed on 5/18/21, it was determined that for one (Resident #22) of three residents reviewed, the facility did not provide the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #22 did not receive nail care or shaving per their preferences. This is evidenced by the following: Resident #22 had diagnoses including vascular dementia without behavioral disturbance, a stroke and muscle weakness. The Minimum Data Set Assessment, dated 2/23/21, documented that Resident #22 was cognitively intact and required assistance of one person for grooming and personal hygiene. The facility policy Quality of Life and Quality of Care , dated January 2020, included the resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good grooming and personal and oral hygiene. Review of the current Comprehensive Care Plan and the Certified Nursing Assistant (CNA) Care Card included the resident required assistance of…

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 reviews conducted during the Recertification Survey, completed on 5/19/21, it was determined that for one of one resident (Resident #44) the facility did not provide care and services consistent with professional standards of care to meet the needs of a resident on dialysis. Specifically, the facility did not monitor the resident's fluid restriction os ordered and did not provide ongoing monitoring and care of the resident's vascular access. This is evidenced by the following: A facility policy, Hemodialysis Guidelines, dated April 2017, directs staff that upon the residents return from dialysis and at least daily, to feel lightly with fingertips over the fistula (a surgical graft used for dialysis) for a thrill (vibration) and auscultate (listen) for a bruit (swishing sound). Staff should document on the treatment sheet that both are present. If there is no bruit and/or thrill present, they should notify the medical provider. Staff are to monitor the site after each…

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.