Inspection·August 7, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on personnel record review, review of criminal background check records, staff interview and review of the facility policy, the facility failed to complete background checks upon hire for new employees. This had the potential to affect all of the residents residing in the facility. The facility census was 137 residents. Findings include:Review of the facility Bureau of Criminal Investigation (BCI) log dated 08/05/25 revealed BCI and Federal Bureau Investigation (FBI) checks had be completed for all new employees. Review of facility personnel records revealed the following staff had not had background checks completed upon hire: Housekeeper #50 hired 05/11/23, Housekeeper #52 hired 05/21/24, Certified Nursing Assistant (CNA) #22 hired 02/15/23, CNA #23 hired 09/26/23, CNA #40 hired 05/10/23, CNA #42 hired 10/23/24, CNA #46 hired 06/12/24, Med Tech (MT) #44 hired 02/21/23, Maintenance Director (MD) #28 hired 05/13/23, Dietary Aide (DA) #56 hired 08/24/23, DA #59 hired 03/09/23, DA #55 hired 06/25/24, DA #63 hired 02/06/25, Administrator hired 02/18/25. During an interview on 08/05/25 at 1:30 P.M., the Administrator verified the facility had not completed BCI and FBI checks for the following new hires: Housekeepers #50 and #52, CNAs #22, #23, #40, #42, and #46, MT #44, MD #28, DAs #56, 59, #55, #63, Administrator. During an interview on 08/06/25 at 4:54 P.M., Employee Lifecycle Manager (ELM) #65 reported it was the facility policy to complete BCI and FBI checks prior to employees being hired. Review of the facility policy titled Abuse/Neglect/Misappropriation of Property dated 05/13/09 revealed the facility employed properly screened persons as a part of the resident care team. The facility would perform an extensive background check for potential employees, which included a BCI and FBI check. Review of the facility's corrective action plan, completed by the Administrator revealed the following actions were implemented and the deficiency was corrected on 06/02/25. On 03/26/25, the Director of Nursing (DON) completed comprehensive abuse questionnaire interviews with residents, with no additional findings. On 03/26/25, the DON performed thorough head-to-toe assessments on residents with severe cognitive impairment who could not provide meaningful information with no new injuries identified. On 03/26/25, the Administrator terminated Human Resource Manager (HRM) #70 because the employee had failed to ensure appropriate background checks for new hires. On 03/26/25, the Administrator conducted a comprehensive, facility-wide audit of staff. Employees found to be noncompliant with background check requirements were promptly removed from the schedule until their BCI checks were successfully completed. By 04/01/25, all identified employees had obtained valid BCI checks with no further findings. On 06/02/25, the Administrator provided education to the new Employee Life Cycle Manager (ELM) #65 who replaced HRM #70 regarding Ohio law requirements for background and abuse checks to ensure full compliance moving forward. To maintain ongoing compliance the Administrator or designee will monitor the completion of BCI checks for new employees on a weekly basis for the next six months. Audit results will be reviewed by the QAPI team initially for two months and subsequently on a monthly basis as needed, to ensure sustained adherence to Residents Affected - Many (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365304 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365304 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clifton Healthcare Center 625 Probasco Street Cincinnati, OH 45220 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)