A list of the most recent deficiencies for Arcadia Care Clifton. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-26 | 2023-12-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-27 | 2023-08-04 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-06 | 2023-05-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-06 | 2023-05-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-06 | 2023-05-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-06 | 2023-05-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-06 | 2023-04-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-10 | 2023-04-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-04-10 | 2023-04-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-04-10 | 2023-04-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-10 | 2023-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-10 | 2023-04-14 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2023-04-10 | 2023-04-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-10 | 2023-04-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-10 | 2023-04-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-10 | 2023-04-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-04-10 | 2023-04-14 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-04-10 | 2023-04-14 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-04-10 | 2023-04-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-04 | 2022-11-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-14 | 2022-11-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-25 | 2022-10-27 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-10-14 | 2022-10-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-29 | 2022-08-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-29 | 2022-08-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-16 | 2022-08-23 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-06-16 | 2022-07-05 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-31 | 2022-04-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-31 | 2022-04-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-30 | 2022-03-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-30 | 2022-03-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-30 | 2022-03-31 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-03-15 | 2022-03-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-15 | 2022-03-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-15 | 2022-03-22 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-15 | 2022-03-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-15 | 2022-03-22 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-03-15 | 2022-03-22 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-15 | 2022-03-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-15 | 2022-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-15 | 2022-03-22 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-15 | 2022-03-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-15 | 2022-03-22 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-15 | 2022-03-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-18 | 2021-11-20 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-18 | 2021-11-20 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-18 | 2021-11-20 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-11-18 | 2021-11-20 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-18 | 2021-11-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-21 | 2021-10-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-21 | 2021-10-26 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-21 | 2021-10-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-17 | 2021-08-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-05 | 2021-08-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-05 | 2021-08-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-02-11 | 2021-03-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-02-11 | 2021-03-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-02-11 | 2021-03-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-02-11 | 2021-03-11 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-02-11 | 2021-03-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-02-11 | 2021-03-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-02-11 | 2021-03-11 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-02-11 | 2021-03-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-02-11 | 2021-03-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-02-11 | 2021-03-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-02-11 | 2021-03-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-02-11 | 2021-03-11 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-02-11 | 2021-03-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-02-11 | 2021-03-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-02-11 | 2021-03-11 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-02-11 | 2021-03-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-02-11 | 2021-03-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-02-11 | 2021-03-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-02-11 | 2021-03-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-02-24 | 2021-03-03 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-02-11 | 2021-02-25 | N |
| Post nurse staffing information every day. | Health | 2021-02-11 | 2021-02-25 | N |
