Clarendon Nursing Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical service to include accurate dispensing and administering of biologicals for 1 of 3 medication storage areas reviewed to meet the needs of each resident. The facility had 8 inulin medications expired according to the date documented on the bottle/pen of when it was opened. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes.

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment requirement for 1 of 1 kitchen staff (Dietary Manager) reviewed for qualifications. The Dietary Manager failed to have the appropriate license, certification, or qualifications to function as the Director of Food and Nutrition Services since her start date in August 2025. This failure could place residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated, freezer, and pantry items were properly stored, labeled, and dated. This failure could place residents at risk of food-borne illnesses.

Inspectors wroteBased on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #36) of 15 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #36's MDS was accurately coded to reflect he received insulin. This failure could place residents at risk of not receiving necessary care. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care for 1 (Resident #34) of 15 residents reviewed for behavioral health services. The facility failed to ensure Resident #34's comprehensive care plan included goals and interventions addressing his documented diagnosis of post-traumatic stress disorder. This failure could place residents at risk for diminished quality of life due to the lack of treatment and prevention to maintain resident safety.

Inspectors wroteBased on record reviews and interviews the facility failed to develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles for 4 out of 5 employees (LVN A, CNA B, CNA C and PTA) reviewed for required training. The facility failed to ensure staff were properly trained in Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures and Dementia for 4 of 5 employees (LVN A, CNA B, CNA C, and the PTA) reviewed for training at hire and annually. This failure could place residents at risk of receiving care from individuals who did not have the knowledge and skills to properly provide safety from adverse events or other resident life and health complications.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 2 CNAs (CNA C) reviewed for CNA certification. The facility failed to ensure CNA C's certification was current before allowing her to care for residents. CNA C worked in the facility providing resident care, on a full-time basis, with an expired certification for the months of February and [DATE]. This failure could place residents who received care from CNA C in medical jeopardy, which could lead to the decreased physical, mental, and psychosocial well-being of each resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food service safety. The facility failed to label and date food in the refrigerator, freezer, and pantry. The facility failed to keep food in the refrigerator and freezer sealed. The facility failed to maintain cleanliness in the pantry. The facility failed to store all food at least 6 inches off the floor in the pantry. These failures could put residents at risk of food and pest borne illnesses. Findings Included: An observation of refrigerator 1 on 10/28/24 at 09:12 AM revealed the following: 1 clear plastic bag open to air containing what appeared to be lunch meat with no label or date. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 3 (Resident #2, Resident #26, and Resident #39) of 15 residents reviewed for accidents and hazards. The facility failed to perform quarterly safe smoking assessments on Resident #2, Resident #26, and Resident #39. These failures could place residents at risk of burns and/or injury. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility to maintain an effective pest control program so that the facility is free of pests for one of one facility reviewed for environment for 3 out of 3 days. -The facility failed to prevent an infestation of flies and gnats based on observations at varied times over a 3-day period from 10-28-2024 to 10-30-2024. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 (Resident #43) of 15 residents reviewed for accuracy of assessments. The facility failed to indicate antipsychotic medication and hospice care on Resident #43's MDS assessment. This failure could place residents at risk of not receiving necessary care and/or services. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 (CNA B) of 5 staff observed for resident care. -CNA B did not perform the proper process, wash her hands, change gloves, or place a residents brief properly while performing incontinent care. This deficient practice has the potential to affect residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents and hazards. Resident #1 was left alone in the shower, fell, and was injured on 10/13/23. Resident #1 was coded as needing assistance by one staff person for bathing in his MDS completed 08/08/23. This failure could place residents requiring assistance with ADLs in danger of injury.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure each resident had the right to formulate an advance directive for 1 (Resident #1) of 6 residents reviewed for advance directives. Resident #1 had a DNR that was signed by the physician in the wrong section and was not dated by the physician. This failure could place residents at risk of not having their end of life wishes honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure the freezer was free from dirt, debris and rust. Freezer items were not properly stored, labeled, and dated. 2. The facility failed to ensure refrigerator and pantry foods were properly stored, labeled, and dated. 3. The facility failed to ensure general cleanliness was maintained in the kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 1 medication rooms. Multiple vials of insulin left out on the counter. -The medication refrigerator was not kept at a temperature between 36 to 46 degrees. The facility's failure to ensure drugs and biologicals were stored in accordance with the currently accepted professional principles, this could place all residents receiving medication that have lost integrity to not receive their therapeutic dose.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and permanently maintain and effective training program for all staff, which includes trainings on abuse, neglect, exploitation, misappropriation of resident property, and dementia management, that is appropriate and effective, as determined by staff for 12 of 15 (ADM, DON, ADON, Dietary Supervisor, Activities Director, MA B, Monitor Tech D, MA E, CNA C, Monitor Tech F, [NAME] G, and [NAME] H) employees reviewed for Abuse, Neglect, and Misappropriation training and Dementia training. The facility failed to ensure all staff were trained at time of hire and annually on Abuse, neglect, exploitation, restraints, and falls. This failure could place all residents at risk for abuse, neglect, exploitation, bodily injury, and decline in overall health.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a base-line care plan with-in 48 hours for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 1 of 15 residents (Resident #14) whose care plans were reviewed. The facility failed to develop a base-line care plan with-in 48 hours of resident admitting into the facility. This failure could place all residents at risk of receiving care that does not meet the initial goals, medication interventions, services or treatments, or updated information related to re-admitting to the facility after 30 days.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 2 of 15 residents (Residents #7 and #16) whose care plans were reviewed. The facility failed to develop a comprehensive person-centered care plan indicating services as follows: 1. Failure to develop person-centered goals reflecting medical needs outside the facility of dialysis for Resident #16 2. Failure to develop person-centered goals reflecting psychosocial needs for activities for Resident #7. These failures could place all residents at risk of receiving care that is substandard, not individualized to the resident, or not meeting the highest practical medical and psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay for 1 (Resident #60) of 2 residents reviewed for discharge summaries. A. The facility failed to ensure a Discharge Summary for Resident # 60 was completed which included a complete recapitulation of the resident's stay for a resident discharged to another facility. This failure could place residents discharged from the facility at risk for incorrect, incomplete, or misleading information recorded regarding discharged residents, and failure in the continuity of care for residents.

Inspectors wroteBased on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The facility did not have an RN in the facility on 06/3/2023, 06/04/2023, and 06/18/2023, accounting for 3 days in the last 90 days. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 of 2 biohazard/sharps containers located at facilities only nurse's station. The facility failed to ensure that residents were safe from exposed biohazard materials. This failure could place the residents at an increased risk for potentially exposing them to, injury, viral infections, secondary infections, and communicable diseases.