Seven Acres Senior Living at Clifton

In the surveyor’s words

From the most serious findings on record at Seven Acres Senior Living at Clifton, in the surveyor’s own words.

• Immediate jeopardy, isolatedF692Mar 29, 2021

  Based on closed medical record review, hospital record review and staff interview, the facility failed to identify a significant decrease in meal intake, failed to provide sufficient fluids to prevent dehydration, failed to monitor fluid intake, failed to facilitate interdisciplinary communication between the doctor, dietitian, and direct care staff regarding a resident's decreased oral intake, and failed to initiate new interventions to address the decreased appetite and oral intake in the care plan following discontinuation of a medication to stimulate appetite. This resulted in Immediate Jeopardy and serious life-threatening harm and/or death when one (Resident #100) suffered an acute change in condition and was sent by emergency squad to the hospital. […]

• Actual harm, isolatedF697Aug 23, 2023

  Based on record review, observation, resident interview, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure Resident #46's pain was managed during a dressing change to the residents Stage IV pressure ulcer (full-thickens loss of skin and tissue loss with exposed or directly palpable fascia, muscle tendon ligament, cartilage, or bone in the ulcer) on her sacrum. This resulted in Actual Harm to Resident #46 when the resident was not pre-medicated for pain prior to the wound care treatment which resulted in the resident exhibiting signs of severe pain and the nurse continued the wound treatment without addressing the resident's pain. […]

• No harm, potential for more than minimal, widespreadF606Apr 29, 2021

  Based on personnel file review, interview and policy review, the facility failed to ensure staff were checked against the Nurse Aide Registry prior to employment. This had the potential to affect all 40 residents residing in the facility. Findings include: Review of personnel records revealed no evidence of employees being checked against the State Nurse Aide Registry prior to employment for the following: Dietary Aide (DA) #92 hired on 08/13/19; DA #36 hired on 03/07/19; DA #94 hired on 10/13/20; DA #56 hired on 07/15/20; DA #51 hired on 08/19/20, DA #30 hired on 12/17/20; and DA #109 hired on 02/04/21. […]

• No harm, potential for more than minimal, patternF883Jun 26, 2024

  Based on medical record review, staff interview, and policy review, the facility failed to ensure resident pneumococcal vaccinations were up to date. This affected five (#15, #17, #18, #19, and #37) of five residents reviewed for pneumococcal vaccinations. The facility census was 51. Findings include: 1. Review of the medical record for Resident #15 revealed an admitted [DATE]. Diagnoses included acute kidney failure, major depressive disorder, acute respiratory failure with hypoxia, and metabolic encephalopathy. Review of the medical record for Resident #15 revealed Pneumococcal vaccine Prevnar 13 was given on 07/21/15. Resident #15 should have received Prevnar 20 (PCV20) or Pneumovax 23 (PPSV23) one year after PCV13; however, there was no documentation either was given. 2. […]

• No harm, potential for more than minimal, patternF803Mar 12, 2024

  Based on observations, medical record review, staff interviews and spread sheet review, the facility failed to serve the correct amount of puree food texture portions as listed on the menu spreadsheet. This affected four (#21, #35, #39 and #47) of four residents observed who required an ordered puree texture diet. The facility total census was 48. Findings include: Review of Residents #21, #35, #39 and #47's monthly March 2024 physician orders revealed the residents had physician orders for puree texture diets. Review of the lunch menu spreadsheet dated 03/07/24 revealed the puree texture diet should have received three ounces puree meat, four ounces of vegetable, and four ounces of starch. […]