Clairidge House

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to implement the abuse policy and ensure alleged violations involving sexual abuse, exploitation, misappropriation of resident property, and/or a reasonable suspicion of a crime against a resident (R) were reported to the State Survey Agency and, when applicable, law enforcement within required timeframes for one of three reportable incidents reviewed affecting (R6). These failures had the potential to delay protective oversight, law enforcement involvement, and required external oversight of allegations affecting residents in the facility. Findings Include: [...]

Inspectors wroteBased on record review, interview and observations, the facility did not ensure residents received comprehensive assessments, interventions and treatment, to prevent and heal, pressure injuries. This was observed with 4 (R3, R9, R1 and R16) of 4 residents reviewed with pressure injury. *R3 was at high risk for a pressure injury, developed a facility acquired stage 3 pressure injury, that was not comprehensively assessed upon discovery. R3 did not have interventions revised to promote healing. This resulted in actual harm to R3. *R9 had facility acquired pressure injuries to the left upper posterior thigh area and left medial thigh. On 3/03/2026, Surveyor observed R9's wound treatment which was not completed per the order. R9's pressure injuries were determined to be due to R9 being provided with the incorrect size brief causing medical device related pressure injuries. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the physician was consulted with regarding a possible change in condition for 1 (R20) of 1 sampled Residents. On 2/19/26 R20's recorded weight was significantly less than their previous weight. The facility did not consult with R2's physician regarding the possible weight loss.

Inspectors wroteBased on record review and interview, the facility did not ensure employees were screened for abuse prior to working at the facility. This was observed in 4 (M, N, O and P) of 8 staff reviewed.*Certified Nursing Assistant (CNA)-M was hired on 6/27/25 and worked out of state. The other state background check was not completed by their hire date.*Dietary Manager (DM) - N was hired on 1/9/25. Their Background Information Disclosure (BID) was not signed and dated. The Departement of Justice (DOJ) was not completed until 3/2/26. The Integrated Background Information System (IBIS) was not completed until 3/2/26.*CNA-O was hired on 1/19/26 and worked out of state. The other state background check was not completed by their hire date.* CNA-P was hired on 6/17/25. The DOJ was not completed until 7/2/25. The IBIS was not completed until 7/2/25.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the environment remained free of accident hazards with smoking materials for 3 (R1, R2, and R16) of 4 residents reviewed for smoking and residents received adequate supervision to prevent accidents for 1 (R20) of 4 residents reviewed for falls. *R1 was observed to be vaping while lying in bed. R1 did not have smoking assessments completed on a quarterly basis. *R2 was observed to have smoking materials in the room; R2's Care Plan documented R2 may not possess any smoking materials including a lighter and all smoking materials were to be kept with the nurse for distribution as requested. R2 did not have smoking assessments completed on a quarterly basis. *R16 did not have smoking assessments completed on a quarterly basis. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure allegations of misappropriation of funds and neglect for two (R19 and R10) of 2 sampled residents were not reported as required. *R19 informed staff of missing money on 1/21/26 and this allegation was not reported to the State Survey Agency. *An allegation of neglect directly affecting R10 was not reported to the State Survey Agency.

Inspectors wroteBased on record review and interviews, the facility did not ensure allegations involving potential misappropriation of funds and neglect were thoroughly investigated for 2 Residents (R19 and R10) of 2 sampled Residents. *R19 informed staff of missing money on 1/21/26 and this allegation was not thoroughly investigated by the facility. *An allegation of neglect directly affecting R10 was not thoroughly investigated by the facility.

Inspectors wroteBased on record review and interview, the facility did not document a summary of information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS) for 2 (R3, and R1) of 5 sampled residents. * R3's admission MDS, completed 7/7/25, Pressure injury Care Area Assessment (CAA) does not contain a comprehensive summary of triggered areas. *R1 had 10 Care Area Assessments (CAAs) triggered to be completed for the admission Minimum Data Set (MDS) assessment dated [DATE]. Documentation of summary information of the ten CAAs was not completed.

Inspectors wroteBased on interview and record review, the facility did not ensure they notified the state mental health authority promptly for a resident review after a significant change in mental condition for 1 (R10) of 1 resident reviewed for PASARR. *R10 demonstrated increased mood related symptoms which required an extensive inpatient psychiatric stay. Following the hospitalization R10 was prescribed psychotropic medication to treat symptoms. R10 was readmitted to the facility and a new PASARR (Preadmission Screening and Resident Review) was not completed and submitted to the state authority to ensure R10 received care and services in the most appropriate setting.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R20) of 1 resident reviewed for diminishing abilities in activities of daily living, received the appropriate treatment to maintain or improve the ability to carry out activities of daily living.

Inspectors wroteBased on interview and record review, the facility did not ensure resident (R20) maintained acceptable parameters of nutritional status for 1 (R20) of 1 sampled residents with weight loss. R20's medical record indicated a deviation in R20's weight that reflected the potential for a severe weight loss. The facility did not reweigh R20 or requested assessment by the registered dietitian with the documented weight changes. The facility did not ensure R20's intake was monitored as care planned.

Inspectors wroteBased on interview and record review, the facility did not provide necessary treatment and services to 1 (R16) 1 sampled residents with a history of substance abuse. R16 has a diagnosis of alcohol abuse and had sustained falls following episodes of drinking. The facility did not review and offer necessary supports toR16 to address substance abuse and to ensure R16's safety when drinking.

Inspectors wroteBased on interview and record review the Facility did not provide appropriate treatment and services for 1 (R20) of 1 sampled residents with a diagnosis of dementia with behavioral symptoms to allow them to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.* R20 was observed during the survey to not receive activities or stimulation based upon individual preferences and identified interests with a diagnosis of dementia. R20 was observed engaging in behaviors of repeatedly tapping and banging objects on tables without redirection or encouragement to do participate in an activity.

Inspectors wroteBased on interview, and record review the facility did not ensure 1 (R10) of 1 resident reviewed received medically related social services to attain their highest practicable mental and psychosocial well-being.* On 1/14/2025, R10 was committed for 6 months on a locked unit at a psychiatric facility for Suicidal Ideation (SI), mania and psychosis with substantial probability of physical harm to self, manifested by overt attempt or threat. R10 readmitted to the facility without a suicidal care plan put into place and no person-centered interventions specific to SI prevention in R10's care plan. Social Service Designee (SSD)-H was not aware of R10's history of SI and was not involved in R10's psychosocial care planning or follow up.

Inspectors wroteBased on interview and record review, the facility did not ensure pharmaceutical services were provided to 1 (R10) of 1 sampled residents receiving pain medications. R10 was seen in the emergency room (ER) on 11/1/25 for hip pain. R10 returned to the facility with recommendations to take Tylenol 650mg 3 times per day with or without ibuprofen 600mg twice a day, as needed for pain. There is no indication this recommendation was reviewed with R10's physician or medication orders at the time were adjusted to implement this recommendation for pain management. Additionally, R10 received multiple doses of as needed (PRN) Tramadol for pain management without a rating of R10's pain prior to administration or documentation of the effectiveness of the medication. Findings Include:The facility's policy, titled Pain Recognition and Management, last revised 4/2025, documents: . 8. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure a resident received an antibiotic medication with adequate indications for use for 1 (R5) of 6 sampled residents.*R5 was prescribed, and administered, the antibiotic (Macrobid) without adequate indications of an infection.

Inspectors wroteBased on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (R9) of 5 residents observed with Enhanced Barrier Precautions (EBP).*R9 has a Facility acquired pressure injury to the left upper posterior thigh area and left medial thigh. On 3/02/2026, Surveyor observed R9's incontinence care and on 3/03/2026, observed R9's wound treatment. The Facility staff did not wear the proper Personal Protective Equipment (PPE) while performing R5's wound treatment or incontinence cares.

Inspectors wroteBased on record review and interview, the facility did not offer the influenza immunization for 2 (R16 and R5) of 5 residents reviewed for immunizations. R5 and R17 were not offered the influenza (flu) immunization on admission to the facility and the facility did not document if the immunizations were offered and declined. Findings Include:The facility policy titled Influenza Immunization - Resident Reviewed 2/25, Revised 2/21 documented:All residents will receive vaccination annually between October 1st and mid November, at the direction of the facility medical director and Q API committee. Residents admitted during the winter months (October 1st through March 31st) will receive influenza vaccination at admission, if they have not already received it unless there is a medical contraindication. [...]

Inspectors wroteBased on record review and interview, the facility did not offer the COVID-19 immunization for 1 (R16) of 5 residents reviewed for immunizations. R16 was not offered the COVID-19 immunization on admission to the facility and the facility did not document if the immunizations were offered and declined. Findings Include:The facility policy titled Coronavirus (COVID-19) Vaccination - Resident. Last reviewed 3/24, last revised 4/25 documented:Coronavirus vaccination is strongly recommended and applies to all the residents. When COVID-19 vaccination is available to the facility, each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident has already been immunized. [...]

Inspectors wroteBased on record review, document review, and staff interview, the facility failed to designate a person to serve as the Director of Food and Nutrition Services. Failure to designate a person had the potential to result in food not being prepared, stored, or served in a sanitary manner with the potential to result in food borne illness. This had the potential to affect all 41 of 41 residents residing in the facility.

Inspectors wroteBased on observation, staff interviews and policy/procedure review, the facility failed to ensure the low temperature dishwasher sanitizer was maintained at a level required to sanitize the dishes. Failure to ensure the sanitizer level of the dishwasher was at the required level had the potential to result in food borne illness or the spread of infections for all 41 of 41 residents residing in the facility.

Inspectors wroteBased on observation, record review, policy review, and interviews, the facility failed to ensure the residents' environment was clean, sanitary, and homelike. This had the potential to result in the spread of infection; residents being injured as the result of a loose toilet seat; a decline in residents' self-esteem. This affected five (Resident (R) 26, R32, R23, R9, and R22) of 41 residents in the facility.

Inspectors wroteBased on observation, record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident out of 28 sampled residents (Resident (R) 36) had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly regarding R36's feeding tube, could lead to inaccurate assessment and care planning of the resident.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident with an indwelling urinary catheter had a physician's order for the use of an indwelling urinary catheter for one of two residents (R)34) reviewed for indwelling urinary catheter care. As a result of this deficient practice, the resident had the potential for harm by staff performing interventions or actions without a physician's order.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure a resident with a feeding tube (gastrostomy tube) had a physician's order for the care and management of the feeding tube for one of one resident (Resident (R)36) reviewed for gastrostomy care. As a result of this deficient practice, the resident had the potential for harm by staff performing interventions or actions without a physician's order.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure one Resident (R)41 out of three residents observed with a medication in a cup on the bedside table was administered his medication when the nurse dispensed the medication. This failure had the potential to place the resident at risk for health decline.

Inspectors wroteBased on record review, document review, policy review, and interviews, the facility failed to ensure controlled substances were under double lock for one of two medication rooms (second floor), and that the individual controlled count sheets reflected the signatures of the nurses who had administered the narcotics to the residents for three of fourteen residents (R) 32, R37 and R24). This failure had the potential for controlled substances to be diverted.

Inspectors wroteBased on staff interviews, record reviews, and document review, the facility failed to ensure the staff were prepared and educated for the care of one resident (Resident (R)26) with a portable infusion pump delivering chemotherapy drugs through a surgically implanted port. As a result of this deficient practice, the residents and staff had the potential for harm and/or injury due to lack of knowledge for: the care of the pump and tubing; awareness of the hazards of the chemotherapy drug and potential exposure risks with a leak or spill; and biohazard containment of a chemotherapy drug if a leak/spill did occur.

Inspectors wroteBased on interview and record review the Facility did not have a system in place on how staff should respond, what staff should do in the event of a Resident requiring cardiopulmonary resuscitation (CPR), and ensure the necessary equipment was provided for R3's code event. This deficient practice has the potential to affect 23 Residents residing in the Facility who have determined their code status to be CPR. On [DATE] R3 had a change of condition which led to CPR being performed. LPN-E started compressions prior to checking R3's code status. LPN-E instructed CNA-F to call 911 and the other nurse, who was working on the other floor. CNA-F was unable to get through to 911 or the other nurse on the telephone. LPN-E while doing compressions used his personal cell phone to call 911. CNA-F had to take the elevator to the 2nd floor to inform RN-D there was an incident with R3. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R6) of 6 Residents was given the right to formulate their preference regarding their code status and have the facility correctly reflect that preference. *R6's POLST (Provider Orders for Scope of Treatment) signed, not dated by R6 is checked for Do Not Attempt Resuscitation/DNR. On [DATE] R6 was hospitalized and returned to the facility on [DATE]. The hospital discharge summary for date of discharge [DATE] documents Code Status: Full Code. R6's medical record contained conflicting details regarding R6's code status and there is no evidence the Facility spoke with R6 regarding this conflicting code status.

Inspectors wroteBased on interview and record review the Facility did not notify a Resident's representative of a new form of treatment involving a cream medication to treat scabies involving 2 (R7 and R3) of 2 Residents reviewed for notification of a representative. *R7 was diagnosed with scabies on 9/14/23 and 10/14/23 with a treatment ordered upon each occurrence. There is no indication in R7's medical record that R7's guardian was notified with each occurrence. *R3 was diagnosed with scabies on 9/17/23 and a new treatment was ordered. R3's activated Health Care Power of Attorney (HCPOA) was not notified. Findings Include: Surveyor reviewed the facility's change in Residents Condition/Status: Resident, Physician and Family/Legal Representative Notification/Consultation policy and procedure last revised 8/21 and notes the following applicable: .5. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that food was stored, prepared and served under sanitary conditions in 1 of 1 serving kitchens. This had the potential to affect all 48 residents currently in the facility. *Opened cereal stored in 12 QT (quart) containers did not have a date. *Expired taco meat dated 8/14/23 was observed in the main cooler. *Unit refrigerator in 3rd floor kitchenette was not monitored for appropriate temperatures and frost build-up was an inch thick on the inside back wall of refrigerator.

Inspectors wroteBased on record review and interview, the facility did not implement an effective Infection Control Program. The facility did not develop an effective Water Management Plan to prevent Legionella. The facility did not maintain accurate Surveillance of infections. This had the potential to effect all 48 residents residing in the facility. -The Water Management Plan did not identify areas of risk, surveillance process, control measures, monitoring, the review process along with identified staff responsible. -The facility did not have accurate data for an effective surveillance program to prevent the spread of infection.

Inspectors wroteBased on observation, interviews and record review the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 elevators in the facility. The facility elevator, which is used by both ambulatory and wheelchair residents, was not in proper working order. While on survey, the doors to the elevator closed quickly, bumping into both Surveyor and residents, causing them to stumble and lose balance.

Inspectors wroteBased on observation, interview and record review the facility did not provide residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 12 (R48) residents residing in the facility. R48 was not provided an appropriate wheelchair to allow her to get out of bed while residing in the facility.

Inspectors wroteBased on record review and interview the facility did not provide residents the right to formulate an advance directive for 1 of 12 (R48) residents residing in the facility. R48 did not have an advanced directive or code status clearly indicated in the event of an emergency.

Inspectors wroteBased on observation and interview the facility did not ensure residents the right to a safe, clean, comfortable and homelike environment. This deficient practice has the potential to affect 1 (R3) of 12 sampled residents. R3 was missing paint on the wall behind the headboard of the bed and there was a large circular hole in the drywall.

Inspectors wroteBased on record review and interview, the facility did not ensure an allegation of abuse, neglect, or misappropriation of resident property for 1 of two facility self-reports reviewed was reported to the State Agency within the required 24 hours. *R43 reported to the Activity Director (AD)-H on the afternoon of 6/10/23 that $40 was missing from R43's wallet. The facility started an investigation into the missing money to determine if the claim was credible before reporting this allegation to the State Agency until 6/12/23.

Inspectors wroteBased on record review and interviews, the facility did not ensure all allegations of abuse, mistreatment, exploitation, misappropriation of property, or mistreatment were thoroughly investigated for 2 (R6 and R43) of 2 self-reports reviewed for abuse, neglect and misappropriation of property. The facility did not interview other residents to determine the scope of the potential allegations. * On 11/10/22 the facility was made aware of an alleged mistreatment and potential abuse of R6 by Certified Nursing Assistant (CNA)-J. The allegation was that the CNA patted R6's buttock during cares and stated that the can of sardines in the room smelled like pussy. An investigation was started and residents were safeguarded from this CNA. R6 was interviewed and other staff. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that instructions for ongoing care were provided to the receiving provider upon discharge and was not documented by a physician for 2 (R50 and R51) of 3 residents reviewed for discharge. *R50 was transferred to the hospital on 7/2/2023 per family request. No transfer summary including the discharge summary was provided to the hospital and the physician did not document an order to have R50 transferred to the hospital. *R51 was discharged to another skilled nursing facility on 6/1/2023 per resident request. No transfer summary including the discharge summary was provided to the receiving facility and the physician did not document an order to have R51 transferred to another facility.

Inspectors wroteBased on record review and interview, the facility did not develop a discharge plan involving the resident, resident's representative, and interdisciplinary team to develop goals of a discharge, document referrals to appropriate entities, revise the care plan to address the changing needs of the resident, and document the evaluation of the resident's discharge needs and discharge plan for 1 (R51) of 2 residents reviewed for discharge. *R51 did not have any documentation in their medical record by any discipline of the desire to discharge to another skilled nursing facility. R51's Discharge Care Plan was not revised to incorporate R51's desire to discharge from the facility. No documentation was found that the facility assisted R51 in referring R51 to another skilled nursing facility. No documentation was found addressing an evaluation of R51's discharge needs.

Inspectors wroteBased on record review and interview, the facility did not develop a discharge summary to include a recapitulation of the resident's stay that includes the course of illness/treatment or therapy with a final summary of the resident's stay for 1 ( R51) of 3 residents reviewed for discharge. *R51 was discharged from the facility on 6/1/2023 to another facility and there was no documented evidence a discharge summary was completed.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents' environment were free from accident hazards and residents received adequate supervision. This was observed with 1 (R15) of 1 residents reviewed for elopement and 1 (R49) of 1 water exceeding safe temperature range. - R15 has a Legal Guardian appointed and was found to have left the facility without staff knowledge or supervision. The local police department contacted the facility to inform them R15 was located at their prior community home. The facility staff was unaware R15 had left the facility until notified by the police. - R49's room hot water temperature was above the safe temperature range for use.

Inspectors wroteBased on record review and interview, the facility did not ensure a resident received an antibiotic per definitions of an infection. This was observed with 1 (R32) of 1 resident's reviewed on antibiotics. R32 was prescribed an antibiotic and did not have documentation to support it use.

Inspectors wroteBased on interview and record review the facility did not ensure that residents received specialized rehabilitative services of physical and occupational therapy that were ordered upon admisstion to the facilty for 1 (R48) of 1 residents reviewed for rehabilitation services. R48 did not receive therapy services as ordered upon admission to the facility.

Inspectors wroteBased on record review and interview, the facility did not ensure a resident received an antibiotic per definitions of an infection. This was observed with 1 (R32) of 1 resident's reviewed on antibiotics. R32 was prescribed an antibiotic and did not have documentation to support it use.