Clarence Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice machine, the range hood and the ceiling vents were free of a buildup of debris and failed to ensure staff wore beard restraints during beverage preparation and clean dishware handling. The facility census was 31. 1. Review of the Dietary Sanitation Evaluation, dated 11/14/25, conducted by the consultant dietitian, showed the ice machine was not clean. Observation on 1/27/26 at 9:35 A.M. showed the ice machine in the dining room had a heavy buildup of black debris in the upper corners inside the unit over the accumulated ice below. Black debris located in the upper right-hand corner was in direct contact with the accumulated ice that had not yet fallen into the storage bin. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one vulnerable resident, (Resident #5), of six sampled residents received protective oversight when Certified Nurse Aide (CNA) A gave the resident access to the CNA's marijuana vape pen to inhale marijuana. The facility also failed to provide protective oversight when staff failed to immediately report to administration when CNA A reported he/she high while under the influence of marijuana while on duty at the facility. The census was 34. [...]

Inspectors wroteRefer to event id XF0F13 Based on interview and record review, the facility failed to report allegations of financial exploitation and sexual abuse of one resident, (Resident #401), in a sample of nine residents, to the state agency per regulation and facility policy. Multiple employees of the facility had financial interactions with the resident whereby the resident's property was sold by the resident and purchased by staff and the resident hired and paid for services provided by staff. The items sold were sold below current market value and amount paid for services provided were at a higher rate compared to similar types of employment. An allegation was made that Certified Nurse Assistant (CNA) I received gifts and was engaged in a sexual relationship with the resident while he/she was employed by the facility. The facility census was 33.

Inspectors wroteRefer to event id XF0F13 Based on interview and record review, the facility failed to fully investigate allegations of financial exploitation and sexual abuse of one resident, (Resident #401), in a sample of nine residents. Multiple employees of the facility had financial interactions with the resident whereby the resident's property was sold by the resident and purchased by staff and the resident hired and paid for services provided by staff. The items sold were sold below current market value and amount paid for services provided were at a higher rate compared to similar types of employment. The facility did not document all actions related to the allegation, did not interview other residents, and did not document actions taken to prevent further abuse. The facility census was 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one resident (Resident #3), in a sample of eight residents, with appropriate care and services to promote the highest possible level of functioning and well being for a resident with dementia, by recognizing and thoroughly addressing the resident's mental and psychosocial needs. The facility did not attempt gradual dose reductions to ensure the resident was on the lowest amount of medication possible, did not document attempts at finding the root cause of behaviors, or evaluate and attempt new interventions, did not provide adequate monitoring of the resident to prevent the resident from leaving the building, from having falls inside and outside the facility (falling in a ditch), or wandering in and out of other resident's rooms to prevent altercations between residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food and beverages in accordance with professional standards for food service safety. Staff failed to ensure foods were stored per the manufacturer's instructions and failed to ensure conduct proper handwashing, hairnet usage, and surface sanitization practices. The facility census was 30. 1. Review of the facility policy, Food Receiving and Storage, revised 11/2022, showed the following: -Foods shall be received and stored in a manner that complies with safe food handling practices; -Food services, or other designated staff, will maintain clean and temperature/humidity-appropriate food storage areas at all times; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide abuse, neglect, and exploitation training as part of the required minimum 12 hours of training per year. The facility census was 30. Review of the facility's policy, Nurse Aide Qualifications and Training Requirements, dated August 2022, showed the following: -Nurse aides will have a minimum of 16 hours of training in the following areas prior to direct contact with the residents: 1. Resident rights including promoting the resident's right to be free from abuse, mistreatment, and neglect and the need to report any instances of such treatment to appropriate facility staff. Review of the facility's annual in-service binder on 1/25/24 at 10:42 A.M., showed the facility did not provide abuse/neglect training in 2023. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for two residents (Resident #283 and #300), and failed to update interventions in the resident's care plan to reflect current care needs for five residents (Residents #3, #4, #13, #20, and #21), in a review of 13 sampled residents. The facility census was 30. Review of the facility policy, Comprehensive Person-Centered Care Plans, revised March 2022, showed the following: -The comprehensive, person-centered care plan is developed within seven days of the completion of the required Minimum Data Set (MDS, a federally mandated assessment instrument) assessment (admission, annual or significant change in status), and no more than 21 days after admission. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to follow the facility policy to identify fall risks, develop interventions to prevent falls, investigate falls for possible causes and/or contributing factors and consistently evaluate, implement, and modify interventions/develop corrective measures to prevent further falls for three residents (Resident #3, #282, and #400) in a sample of eight residents. The facility census was 33. Review of the facility policy, Falls and Fall Risk, Managing, revised 2018, showed the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure as needed (PRN) orders for psychotropic medications for one resident (Resident #20), in a review of 13 sampled residents, were limited to 14 days as required, except if an attending or prescribing physician believed that it was appropriate for the PRN order to be extended beyond 14 days. The facility failed to attempt a gradual dose reduction (GDR) for psychotropic medications or document a clinical justification to continue current dosage for two residents (Residents #3 and #5), in a review of 13 sampled residents. The facility census was 30. Review of the facility's Psychotropic Medication Use policy, dated July 2022, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete tuberculin (TB) skin testing as required of three residents (Residents #6, #13 and #14) at admission, and failed to complete an annual tuberculin screening to rule out signs, symptoms and exposure to TB for one resident (Resident #3), in a review of 13 sampled residents. The facility also failed to ensure a urinary catheter drainage system was maintained to prevent contamination for three residents (Residents #6, #11, and #21). The census was 30. Review of the facility policy Infection Control dated 10/2018, showed the infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of the infection control policies and practices are to: [...]

Inspectors wroteBased on interview and record review, the facility failed to report allegations of financial exploitation and sexual abuse of one resident, (Resident #401), in a sample of nine residents, to the state agency per regulation and facility policy. Multiple employees of the facility had financial interactions with the resident whereby the resident's property was sold by the resident and purchased by staff and the resident hired and paid for services provided by staff. The items sold were sold below current market value and amount paid for services provided were at a higher rate compared to similar types of employment. An allegation was made that Certified Nurse Assistant (CNA) I received gifts and was engaged in a sexual relationship with the resident while he/she was employed by the facility. The facility census was 33. [...]

Inspectors wroteBased on interview and record review, the facility failed to fully investigate allegations of financial exploitation and sexual abuse of one resident, (Resident #401), in a sample of nine residents. Multiple employees of the facility had financial interactions with the resident whereby the resident's property was sold by the resident and purchased by staff and the resident hired and paid for services provided by staff. The items sold were sold below current market value and amount paid for services provided were at a higher rate compared to similar types of employment. The facility did not document all actions related to the allegation, did not interview other residents, and did not document actions taken to prevent further abuse. The facility census was 33. Review of the facility's undated policy, Abuse/Neglect or Misappropriation of Resident Property, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and provide a copy of a baseline care plan, consistent with the resident's specific conditions, needs, and risks that provide effective person-centered care that met professional standards of quality of care within 48 hours of admission to the facility, for two residents (Residents #283 and #300), in a review of 13 sampled residents. The facility census was 30. Review of the facility's policy, Baseline Care Plans, dated March 2022, showed the following: -A baseline plan of care to meeting the resident's immediate health and safety needs is developed for each resident within 48 hours of admission; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physicians orders for two residents (Residents #20 and #11), in a review of 13 sampled residents, by not providing nutritional supplements as ordered. The facility census was 30. 1. Review of Resident #20's weight record showed the following: -Weight on 6/1/23 was 107.9 pounds (lbs); -Weight on 12/4/23 was 96.2 lbs (a 10.59 % weight loss in six months). Review of the resident's care plan, last revised 11/7/23, showed the no documentation the resident had weight loss or was to receive a house supplement (a liquid nutritional supplement) three times a day (as ordered on 3/8/22). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by the facility, dated 12/9/23, showed no weight loss or gain. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a notice of transfer to the resident and/or resident representative when four residents (Residents #3, #4, #13, and #20), in a review of 13 sampled residents, were transferred to the hospital. The facility census was 30. Review of the facility's policy, Notice of Transfer or Discharge (Emergent or Therapeutic Leave), dated October 2022, showed the following: -Under the following circumstances, the notice is given as soon as practicable but before the transfer or discharge: a. The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; b. An immediate transfer or discharge is required by the resident's urgent medical needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information of the facility's bed hold policy to the resident and/or the resident's representative prior to transfers of a resident to the hospital for three residents (Resident #3, #4, and #20), in a review of 13 sampled residents. The facility census was 30. Review of the facility's policy, Bed-Holds and Returns, dated October 2022, showed the following: -All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. Notice 1: well in advance of any transfer (e.g., in the admission packet); and b. Notice 2: [...]

Inspectors wroteBased on interview and record review, facility staff failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. The facility census was 36. Review of the facility's Daily Census Report, dated 5/24/21, showed the facility census was 36. During an interview on 5/27/21 at 9:28 A.M., the administrator said the facility did not develop a facility assessment. The administrator said he/she was not aware a facility assessment was required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quarterly statements of the resident trust funds account to the resident or their representative for all residents who maintained a balance in the resident trust fund, including petty cash. The facility census 36. During an interview on 6/7/21 at 11:18 A.M., the administrator said the facility had not been able to locate a written policy on quarterly statements provided to residents or their representatives. Review of the facility's current balance report for the resident trust fund savings account, dated 5/24/21, showed the facility managed funds in the account for two residents. Observation on 5/25/21 at 3:40 P.M. showed the facility managed petty cash (as a part of the resident trust fund) for 21 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to the Ombudsman, the resident, and/or resident representative when five residents (Resident #10, #15,#16, #31 and #35), in a review of 12 sampled residents, were transferred to the hospital. The facility census was 36. Review of the facility's Notice of Emergency Transfers (undated) showed the following: -When a resident is temporarily transferred on an emergency basis to an acute care facility. notice of the transfer may be provided to the resident and resident representative as soon as practicable, according to 42 CFR 483.15; -Documentation in the resident progress notes stating the resident or resident representative has been notified will meet the criteria for notification of emergency transfer. 1. Review of Resident #31's medical record showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents and resident representatives of the facility's bed hold policy at the time of transfer to the hospital for five residents (Resident #10, #15, #16, #31, and #35), who were transferred to the hospital, in a review of 12 sampled residents. The facility census was 36. Review of the facility's Bed Holds and Returns Policy, revised March 2017, showed the following: -Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy; -The written information given to residents and the resident representatives will explain in detail the rights and limitations of the resident regarding bed-holds, the reserve bed payment policy, the facility daily rate required to hold a bed, and the details of the transfer. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement, evaluate, and modify interventions as necessary to address prevention of falls for two residents (Resident #10 and # 22) with a history of repeated falls, and failed to evaluate the safety risks and provide adequate monitoring for one resident (Resident #31) to prevent injury while smoking. A sample of 12 residents was selected for review. The facility census was 36. Review of the facility's Falls-Clinical Protocol Policy, revised March 2018, showed the following: -The staff and practitioner will review each resident's risk factors for falling and document in the medical record; -The staff will evaluate and document falls that occur while the individual is in the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an antibiotic stewardship program as a part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 36. Review of the facility's Antibiotic Stewardship Policy, revised December 2016, showed the following: -Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing; -Appropriate indications for use of antibiotics include criteria met for clinical definition of active or suspected sepsis, and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending); [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a policy addressing cardiopulmonary resuscitation (CPR, process of providing rescue ventilation and chest compressions to maintain circulation of blood) requirements for staff; and failed to ensure CPR certified staff were trained and available to provide CPR when transporting residents who requested to be a full code (CPR required in the event of cardiac or respiratory arrest) in the facility van. This failure had the potential to affect two residents (Residents #33 and #35), in a review of 12 sampled residents, who were identified as full code status per their medical record. The facility census was 36. 1. Review of Resident #33's medical record showed he/she was full code status. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to obtain physician's orders for the treatment of a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer for two residents (Residents #15 and #23) in a review of 12 sampled residents. The facility also failed to consistently complete and document assessments of residents' skin and failed to assess and document resident's risk for pressure ulcer development. The facility census was 36. [...]