Clifton Heights

In the surveyor’s words

From the most serious findings on record at Clifton Heights, in the surveyor’s own words.

• Immediate jeopardy, patternF600Aug 11, 2023

  Based on interview, record review, and review of the facility's documentation and policy, it was determined the facility failed to protect residents from abuse for six (6) out of thirty-nine (39) sampled residents. (Resident #7, Resident #4, Resident #70, Resident #15, Resident #89, and Resident 46). 1. The facility failed to protect Resident #7 from abuse. On 07/20/2023 the Executive Director (ED) received an anonymous call reporting an inappropriate relationship between a staff member and Resident #7 that involved text messages and nude photos. The facility, however, failed to protect the resident from abuse and continued to allow the staff member to work, gaining access to the resident to potentially abuse the resident further. […]

• Immediate jeopardy, patternF835Aug 11, 2023

  Based on interview, record review, review of the facility's policies, documents, Job Descriptions, and Plan of Correction (PoC) submitted for the 06/10/2023 and 09/13/2021 it was determined the facility failed to have an effective system to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of the facility's Standard Recertification and Abbreviated Plan of Correction (POC) for the 06/11/2023 survey revealed the facility was cited at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F609) failure to report allegations of abuse to State Agencies. […]

• Immediate jeopardy, patternF867Aug 11, 2023

  Based on interview, record review, review of the Administrator's Job Description, review of the Statement of Deficiencies (SoD) submitted for the 06/11/2023 and the Plan of Correction (POC) submitted for the 09/17/2021 survey and review of the facility's policy, it was determined the facility failed to have an effective process in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure they developed, implemented, and maintained an effective, comprehensive, data driven QAPI program that focused on indicators of the outcomes of care and quality of life. […]

• Immediate jeopardy, isolatedF697Nov 22, 2025

  Based on record review, interview, and review of the facility's policies, it was determined the facility failed to ensure an effective pain management regimen, based on a thorough assessment and a person-centered care plan, was implemented for 1 of 11 sampled residents receiving scheduled pain medications (Resident (R) 1). The facility failed to administer pain medication as ordered to R1, who had a history of chronic pain and required multiple daily doses of a potent opioid analgesic. […]

• Immediate jeopardy, isolatedF607Aug 11, 2023

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure its policy was implemented related to completing a thorough investigation, ensuring staff reported without fear of retaliation, and failed to have an effective Quality Assurance and Performance Improvement (QAPI) program to ensure measures were taken, to protect the residents from abuse for one (1) of thirty-nine (39) sampled residents, Resident #7. Review of the facility's Alleged Abuse Incident Nursing Description Note, dated 07/20/2023, revealed an anonymous call was received by the Executive Director (ED) during which the caller reported a relationship involving texting and sending inappropriate pictures via text messages to a resident (Resident #7) by a facility… […]