Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clifton Rehabilitation Nursing Center during CMS and state inspections, most recent first.
Two cognitively intact residents, one with significant neurologic and orthopedic conditions and another with HTN, COPD, PVD, and polycythemia vera, were not treated with dignity and respect when a CNA, after overhearing a complaint, entered a bathroom where a resident was being toileted, tapped the resident on the shoulder, and loudly questioned what she had done, causing the resident to feel uncomfortable and state the CNA was mean and did not like them. The CNA then angrily confronted another resident in their room, loudly using profanity while questioning whether the resident had seen her make the bed; the resident rebuked the CNA for speaking that way and later described the behavior as disrespectful and unprofessional. Staff witnesses reported the CNA appeared angry, spoke loudly, and used the word "fuck," and the CNA later admitted losing her temper, using profanity, and being disrespectful toward residents and coworkers.
The facility did not maintain an effective infection prevention and control program, specifically failing to implement a comprehensive water management plan to prevent Legionella growth. Water testing revealed positive results for L. pneumophila in two areas, but no mitigation or follow-up actions were taken. Facility leadership was unaware of the positive results, and water temperatures in resident areas were kept below recommended levels for Legionella control.
The facility failed to address ongoing concerns from the Resident Council about cold food and not receiving selected menu items. Despite repeated complaints from residents, the Food Service Director and Dietitian did not investigate or document responses to these issues, leaving them unresolved.
The facility failed to develop and implement individualized care plans for four residents, leading to deficiencies in addressing their specific needs. One resident did not have a care plan for insomnia treatment, two residents at high risk for falls did not have prescribed fall prevention interventions in place, and another resident with lymphedema did not have a care plan for the use of a compression sleeve and glove.
The facility failed to prepare and serve meals that were palatable and at safe temperatures. Multiple residents reported issues with cold and flavorless food, which were confirmed by test trays showing inappropriate food and drink temperatures. The FSD and Administrator acknowledged these deficiencies.
The facility failed to follow food safety and sanitation policies, leading to the potential spread of foodborne illness. Observations revealed undated and unlabeled food items, expired food, and unclean microwaves in three nourishment kitchenettes. Interviews with staff confirmed that these issues were not in line with the facility's policies.
A nurse failed to follow proper infection control practices, including hand hygiene between resident care and glove changes, and proper disinfection of blood glucose monitoring equipment. The nurse did not perform hand hygiene as required and improperly disinfected the glucometer by wrapping it in a wet wipe instead of allowing it to air dry.
The facility failed to address and document grievances raised by residents and their family members regarding long call light wait times and missing items. Staff did not follow the facility's grievance policy, resulting in unresolved issues and a lack of accountability.
The facility failed to provide necessary respiratory care and services for three residents by not ensuring that oxygen and BiPAP tubing were changed and stored in a sanitary manner as per facility policy. Observations and interviews confirmed that the required standards were not met.
A facility failed to ensure a resident had a documented rationale and appropriate monitoring for the ongoing PRN use of Trazodone. The resident's medical record did not indicate a diagnosis of insomnia, and care plans did not reflect the use of psychotropic medications for insomnia or any non-pharmacological interventions. The medication's purpose was inconsistently documented, and the resident used the medication infrequently, suggesting it might not be necessary.
The facility failed to ensure proper storage and administration of medications for three residents. Medications were left at the bedside without proper consent or evaluation for self-administration, contrary to the residents' care plans and physician's orders.
Failure to Treat Residents With Dignity and Respect During Verbal Confrontation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that two cognitively intact residents, both able to communicate their needs and act as their own decision-makers, were treated with dignity and respect by a CNA. One resident had multiple diagnoses including lumbar disc disease/spinal stenosis, cerebral infarct, facial weakness, hemiplegia, dysarthria, dysphagia, right femur fracture, and anxiety, and required staff assistance for care needs. The other resident had hypertension, COPD, peripheral vascular disease, and polycythemia vera, and required supervision for ADLs. The facility’s Resident Rights policy stated that residents have the right to be treated with respect and dignity. On the date of the incident, while one resident was being assisted with toileting and morning care by another CNA, that resident was observed to be tearful and upset and stated that the involved CNA was mean to him/her. The involved CNA overheard this discussion, entered the bathroom where the resident was holding the grab bars and facing the wall, tapped the resident on the shoulder, and in a loud voice questioned the resident about what she had done, asking, "I did something to you?" The resident later reported feeling uncomfortable when the CNA came over his/her shoulder and spoke loudly, and stated that the CNA was in a bad mood and did not like him/her. Initial statements also indicated an allegation that the CNA had pulled the resident’s hair, though the resident later reported that hair pulling had not occurred. After leaving the bathroom, the CNA appeared angry and was heard speaking loudly in Portuguese, stating, "I did nothing." The CNA then approached the second resident, stood in the doorway, and loudly questioned whether the resident had seen her providing care earlier, saying, "You did not see my fucking face make your bed?" The second resident responded, "Don't you dare talk to me like that," and later described the CNA’s conduct as disrespectful and unprofessional toward residents and staff. Other staff, including a lead CNA, overheard the commotion, observed the CNA speaking loudly and using profanity toward the resident, and confirmed that the CNA was angry. In a subsequent interview, the CNA admitted losing her temper, using profanity, and being disrespectful toward residents and coworkers.
Failure to Maintain Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the management of water systems to prevent the growth and transmission of Legionella and other waterborne pathogens. Review of facility policies and CMS guidance revealed requirements for a comprehensive water management plan, including risk assessments, temperature controls, routine maintenance, and protocols for testing and responding to positive Legionella results. However, the facility's water management plan did not identify areas at risk for Legionella growth or outline mitigation strategies in the event of positive test results. Laboratory testing of the facility's water system detected L. pneumophila in two locations, with results of 47 MPN/ml and 10 MPN/ml, which are considered cause for concern according to CDC guidelines. Despite these findings, there was no evidence that the facility took any mitigation actions or conducted further testing in response to the positive results. The Director of Maintenance was unaware of the positive Legionella results and did not implement any temperature controls or other measures specifically aimed at preventing Legionella growth in the resident water supply. Interviews with facility leadership, including the Administrator and Director of Maintenance, confirmed a lack of awareness regarding the positive Legionella test results and the absence of any follow-up actions or environmental assessments. The facility's water temperature logs indicated that hot water in resident areas was maintained between 109.9°F and 111.4°F, below the recommended levels for Legionella control. The facility's water management plan and practices did not align with federal and industry standards for Legionella prevention, contributing to the identified deficiency.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to act promptly and demonstrate their response to concerns brought forth by the Resident Council. From November 2023 to March 2024, residents repeatedly voiced concerns about receiving cold food and not getting their selected menu items during Resident Council meetings. Despite these ongoing complaints, there was no documentation or evidence that the facility resolved these issues. The Food Service Director (FSD) and the Dietitian attended some of the meetings but did not conduct any audits or investigations, nor did they provide documented responses to the residents' concerns. The Activity Director (AD) acknowledged that similar food-related concerns were raised month after month without resolution. Interviews with the FSD, Dietitian, and AD revealed that the facility lacked a process for addressing and documenting responses to Resident Council concerns. The FSD admitted to telling residents to ask nursing staff to reheat their food but did not take further action to investigate or resolve the issues. The Dietitian was unaware of the need to investigate the concerns and did not follow up. The AD confirmed that the food-related issues remained unresolved and that there was no formal process for providing responses to the Resident Council. Resident #36, who regularly attended the meetings, confirmed that the concerns about cold food and not receiving preferred menu items were ongoing and unresolved.
Failure to Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized resident-centered care plans for four residents, leading to deficiencies in addressing their specific needs. For Resident #78, the facility did not create a care plan for the treatment of insomnia using PRN Trazodone, despite the resident having a history of insomnia and receiving the medication multiple times. The care plans in place did not reflect the resident's use of psychotropic medications for insomnia, and the issue was confirmed by both the Unit Manager and the Director of Nurses (DON). Resident #29, who had a history of falls and was at high risk for further falls, did not have the prescribed fall prevention interventions implemented. The care plan required bright colored tape on the call light for better visibility and anti-slip material on the wheelchair, but these were not in place during multiple observations. The resident confirmed the absence of the bright colored tape, and the Unit Manager and DON acknowledged the failure to follow the care plan. Resident #74, also at high risk for falls, did not have the required anti-slip material or Dycem on the chair cushion as specified in the care plan. Observations over several days confirmed the absence of these interventions, and the Unit Manager and DON admitted that the care plan was not being followed. Additionally, Resident #1, who had lymphedema, did not have a care plan for the use of a compression sleeve and glove, despite recommendations from a Lymphedema Clinic. Interviews with staff revealed inconsistencies in the application of the compression garments, and the Unit Manager admitted the care plan was not updated to reflect the resident's needs.
Deficiency in Meal Preparation and Serving
Penalty
Summary
The facility failed to prepare and serve meals in a manner that conserved flavor, were palatable, and served at safe and appetizing temperatures. During initial resident screening, multiple residents expressed concerns about the food being cold, lacking flavor, and having a strange consistency. These concerns were consistently documented in Resident Council Meeting Minutes over several months, indicating ongoing issues with food quality and temperature. Specific complaints included cold eggs, cold coffee and tea, salty or peppery food, lumpy potatoes, and withered lettuce in salads. The Food Service Director (FSD) was aware of these concerns and attended Resident Council Meetings when invited. Test trays conducted by the surveyor confirmed these issues. A lunch test tray showed that herbed chicken, wax beans, and whole milk were served at inappropriate temperatures, with the wax beans being cold and flavorless. A breakfast test tray revealed that French toast, scrambled eggs, and drinks were served at temperatures that were too cool or warm. The FSD acknowledged these deficiencies, stating that meals should be warm and flavorful when delivered to residents. The Administrator also reviewed the findings and agreed that items should be held to appropriate temperatures and be flavorful when served.
Failure to Follow Food Safety and Sanitation Policies
Penalty
Summary
The facility failed to follow their policy and professional standards of practice for food safety and sanitation, leading to the potential spread of foodborne illness among residents. Specifically, the facility did not properly label and date food products and failed to maintain clean equipment in three nourishment kitchenettes. Observations revealed multiple instances of undated and unlabeled food items, expired food, and unclean microwaves with food particle splatter and stains in the resident refrigerators and nourishment kitchenettes on the [NAME] Two Unit, East Two Unit, and [NAME] One Unit. During interviews, the Food Service Director (FSD) confirmed that the nourishment kitchenettes and resident refrigerators are supposed to be stocked and cleaned by the kitchen's nourishment aide three times a day. The FSD acknowledged that food items brought in from outside should be labeled with the resident's name and the date they were brought in, and any items that are not properly labeled or expired should be removed. Certified Nurse Assistant (CNA) #6 also stated that food items brought to the facility must be labeled and dated, with the resident's name and the date the item was put in the refrigerator. The Administrator confirmed that all nourishment kitchenettes should always remain clean and that food products brought into the facility by visitors should not be expired and should be properly labeled and dated. Despite these policies, the surveyor's observations indicated that these standards were not being consistently followed, resulting in the presence of expired and improperly labeled food items, as well as unclean equipment in the nourishment kitchenettes and resident refrigerators.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow proper infection control practices, specifically in hand hygiene and the disinfection of blood glucose monitoring equipment. During an afternoon medication pass, a nurse was observed not performing hand hygiene between resident care and glove changes. The nurse handled various items, including medication containers, a computer keyboard, and medication cards, without washing hands between tasks. Additionally, the nurse did not perform hand hygiene after removing gloves and before moving the medication cart to another room. These actions were contrary to the facility's hand hygiene policy, which mandates hand hygiene between resident contacts, after handling contaminated objects, and before and after glove changes, among other instances. The nurse also failed to properly disinfect blood glucose monitoring equipment. The facility's policy requires the glucometer to be cleaned and disinfected with a wipe pre-saturated with an EPA-registered healthcare disinfectant, allowing it to air dry for two minutes. However, the nurse was observed cleaning the glucometer by wiping it down and wrapping it in the wet wipe, then placing it on top of the medication cart without allowing it to air dry. The nurse then moved the medication cart to another room without performing hand hygiene. This practice was inconsistent with the facility's policy and the manufacturer's instructions for the disinfectant wipes. Interviews with the nurse, unit manager, and Director of Nursing (DON) confirmed that the observed practices did not align with the facility's infection control policies. The nurse admitted to not performing hand hygiene as required and to wrapping the glucometer in the disinfectant wipe instead of allowing it to air dry. The unit manager and DON both stated that hand hygiene should be performed between every resident and before and after glove changes, and that the glucometer should be allowed to air dry for two minutes after disinfection to ensure proper sanitization.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to properly address and document grievances raised by residents and their family members. Resident #121 and their family member voiced concerns about long call light wait times during a care plan meeting and subsequent interactions with the Unit Manager and Director of Nurses. Despite these concerns being raised, no grievance forms were completed, and the issues were not documented or resolved promptly. The Director of Nurses and Unit Manager failed to recall specific details of the complaints and did not follow the facility's grievance policy, which mandates the recording and resolution of grievances. Similarly, Resident #86 and their family member reported missing items, including money, during a care plan meeting. The Unit Manager acknowledged the concerns but did not complete a Missing Item Report, as required by the facility's policy. The Social Worker and Unit Manager both failed to document the grievances, and the Director of Nurses confirmed that the process for handling missing items was not followed. The facility's grievance binder did not contain any forms related to these incidents, indicating a systemic failure to address and document grievances. The facility's policy on resident and family grievances requires prompt efforts to resolve complaints and proper documentation of all grievances. However, the staff's failure to adhere to this policy resulted in unresolved issues and a lack of accountability. The deficiencies highlight the need for better adherence to grievance procedures to ensure residents' concerns are addressed and resolved in a timely manner.
Failure to Provide Necessary Respiratory Care and Services
Penalty
Summary
The facility failed to provide necessary respiratory care and services for three residents. For Resident #4, the facility did not ensure that oxygen tubing was changed and stored in a plastic bag when not in use, as per facility policy. Observations over several days showed that the nasal cannula tubing attached to the portable oxygen tank was lying across the back of the wheelchair without a storage bag. Interviews with the nursing staff and the Director of Nursing confirmed that the tubing should be changed weekly and stored in a bag when not in use, but this standard was not met for Resident #4. For Resident #221, the facility did not store the BiPAP respiratory tubing and nasal pillow in a sanitary way when not in use. Observations revealed that the BiPAP tubing and nasal pillow were hanging over the siderail of the resident's bed and not stored in a plastic respiratory bag. The resident confirmed that staff cleaned the equipment but did not provide a storage bag. Interviews with the Unit Manager and the Director of Nursing indicated that the facility's protocol was to store BiPAP equipment in a respiratory bag when not in use, but this was not followed for Resident #221. For Resident #32, the facility did not ensure that oxygen tubing was changed and stored in a plastic bag when not in use. Observations showed that the oxygen machine's nasal cannula and tubing were not stored in a bag and were not dated correctly. Interviews with the resident and nursing staff confirmed that the tubing should be changed weekly and stored in a bag when not in use, but this was not done for Resident #32.
Lack of Documentation and Monitoring for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident had a documented rationale and appropriate monitoring for the ongoing, as-needed (PRN) use of a psychotropic medication. The resident, who was admitted with diagnoses including mood disorder, depression, delusional disorder, and hallucinations, had a PRN Trazodone order for insomnia that was routinely re-evaluated and extended without proper documentation. The medical record did not indicate a diagnosis of insomnia, nor did it show that the resident was being monitored for sleeplessness or insomnia. Additionally, the care plans did not reflect the use of psychotropic medications for insomnia or any non-pharmacological interventions attempted to assist the resident in getting restful sleep without medication. The psychoactive PRN medication evaluation forms showed inconsistencies and lacked a rationale for the continued use of the PRN medication. The forms initially indicated the medication was for insomnia but later changed to anxiety without explanation. The medication administration record (MAR) indicated infrequent use of the PRN Trazodone, suggesting it might not be necessary. The Unit Manager and Director of Nurses (DON) acknowledged the lack of documented rationale and the potential error in changing the medication's purpose from insomnia to anxiety. The progress notes and physician notes from February through April did not provide evidence of a documented diagnosis of insomnia or a clinical rationale for the ongoing PRN Trazodone use. The DON concluded that the medication was likely no longer necessary for the resident, and there was no documentation by the physician to indicate that the benefits of the medication outweighed the risks.
Improper Storage and Administration of Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and administered in accordance with professional principles. For Resident #8, morning medications were left at the bedside instead of being administered under direct supervision. The resident, who was cognitively intact, had no care plan or physician's order to self-administer medications, yet the medications were signed off as administered by the nurse. For Resident #106, Saline 0.65% Nasal Spray was left at the bedside, and the resident did not have a self-administration consent or evaluation. The nurse admitted that the resident probably self-administers the nasal spray when feeling dry, despite the resident's preference for medication administration by nursing staff and the absence of a care plan or physician's order for self-administration. Resident #112 had Fluticasone Propionate Nasal Spray stored at the bedside without a self-administration consent or evaluation. The resident's care plan and physician's orders did not indicate self-administration, yet the nasal spray was observed on the nightstand. The Director of Nurses confirmed that none of these residents should have medications at their bedside and that all medications should be administered under direct observation by the nurse.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Somerset
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Somerset Ridge Center | 0.7 mi | ★★★★★ | 14 | 0 |
| Fall River Jewish Home | 1.6 mi | ★★★★★ | 0 | 0 |
| Kimwell Nursing And Rehabilitation | 1.7 mi | ★★★★★ | 13 | 0 |
| Fall River Healthcare | 1.8 mi | ★★★★★ | 14 | 0 |
| The Grove At Carvalho | 2.2 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.