Clifton Springs Hospital and Clinic Extended Care

In the surveyor’s words

From the most serious findings on record at Clifton Springs Hospital and Clinic Extended Care, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF580Nov 15, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF656Nov 15, 2024

  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). […]

• No harm, potential for more than minimal, isolatedF658Nov 15, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF689Nov 15, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF689Mar 3, 2023

  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. […]