La Bella at Clifton

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 10, 2023

  Based on observation, interview, and record review, the facility failed to ensure a resident was properly secured during a vehicle transport while sitting in a wheelchair, failed to ensure a resident had a properly fitting wheelchair for safe positioning, failed to assess a resident with potential for injury after sliding off the wheelchair prior to moving them, and failed to immediately report the accident to facility administration for one of three residents (R14) reviewed for accident hazards on the sample list of 26. […]

• Immediate jeopardy, isolatedF600Nov 18, 2021

  Based on record review and interview, the facility failed to supervise a resident (R2) with known sexual behaviors to ensure protection from non-consensual sexual abuse of another resident (R1), and failed to protect a vulnerable cognitively impaired resident (R1) without the mental capacity to consent to sexual activity. This failure affects two (R1 and R2) of five residents reviewed for sexual abuse in the sample of 17. Staff allowed R2 unrestricted access to R1, resulting in R1 being sexually abused by R2. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 11/16/21, the facility remains out of compliance at severity level two. […]

• Actual harm, isolatedF600Apr 15, 2025

  Based on observation, interview, and record review the facility failed to protect a resident's (R1) right to be free from physical abuse by another resident (R2). This failure affects two (R1, R2) of seven residents reviewed for abuse in the sample list of 14. This failure resulted in R2 abusing R1, causing R1 to experience psychosocial harm as evidenced by crying and fear of R2. Findings include: On 4/14/25 at 8:14 AM R1 was in a wheelchair and slowly propelled herself into her room. R1 stated R1 wishes another resident, R2, wasn't here in the facility. R1 stated a couple weeks ago around 5:00 PM, while in the main dining room, R2 hit R1 in the back of the neck. R1 demonstrated this with an open palm. R1 stated this caused R1 to have neck pain for a few days after the incident. […]

• Actual harm, isolatedF760Jul 8, 2024

  Based on interview and record review the facility failed to ensure a resident's opioid pain medication was administered as prescribed to avoid a potential lethal dosage for one of three residents (R1) reviewed for significant medication errors in the sample list of three. This failure resulted in R1 receiving a dose of Narcan (opioid reversal medication) and being transported by ambulance to the emergency room for evaluation. Findings include: The facility's Medication Administration Policy with a Revised date of [DATE] documents, Medications must be administered in accordance with a physician's order, e.g. (example), the right resident, right medication, right dosage, right route and right time. Do not administer a medication if you note a change in its color, consistency, and/or odor. […]

• Actual harm, isolatedF689May 21, 2024

  Based on interview and record review, the facility failed to maintain and monitor adaptive devices to ensure proper functioning to prevent a fall for one of one resident (R53) reviewed for falls on the sample of 36. This failure resulted in R53's unsecured toilet seat riser sliding off the toilet when R53 was sitting and/or transferring onto the toilet, causing R53 to fall. R53 sustained a fractured finger and laceration requiring three sutures. Findings Include: R53's Fall Risk assessment dated [DATE] documents R53 is at risk for falls. R53's MDS (Minimum Data Set) dated 3/1/24 documents R53 has severe cognitive impairments. R53's Progress Notes document the following: 2/18/24 - CNA (Certified Nursing Assistant) heard R53 yelling. […]