Clark Manor

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to report an allegation of abuse, to the facility Administrator/Abuse Coordinator, for one resident (R1) in a sample of four residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy and procedure. Facility employees failed to report an abuse allegation to the abuse coordinator. This failure affected one (R1) out of four residents reviewed for abuse. The Findings Include: R1's clinical records show an admission date of 3/25/25. R1's Minimum Data Set, dated [DATE] shows R1's BIMS (Brief Interview for Mental Status) score was 13 (Cognitively Intact). On 12/23/25 at 9:57 AM, R1's lying comfortably in bed noted with forgetfulness. Dry dressing noted on R1's forehead. R1 stated that Friday morning, a CNA [Certified Nursing Assistant] was mad at R1 for pressing the call light too many times, took the bed control remote and hit R1 on the forehead. R1 denied being hit on the stomach or with a wet diaper. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to maintain an effective pest control program so that the facility is free of rodents on 3 of 4 resident floors.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents are free from abuse for one of three residents (R1) reviewed for abuse in a total sample of four residents.

Inspectors wroteBased on interview and document review the facility failed to ensure the rights of residents to be free from abuse in one of four residents (R1, R7, R8 and R10) in a sample of 10 residents. This resulted in R7 sustaining a superficial scratch to left side of face near eye.

Inspectors wroteBased on observation, interview, and record review the facility failed to a) ensure a residents' self-releasing seat belts (used to keep a resident positioned properly in their wheelchair) were secured in a manner which allowed the residents to freely release the belt, b) failed to complete an assessment for the need of a restraint and c) failed to code the Quick Release Belt in the MDS (Minimum Data Set) as a restraint for 1 (R1) out of 3 residents reviewed for physical restraints. Findings Include: [...]

Inspectors wroteBased upon observation, interview, and record review the facility failed to ensure accuracy of wound location, failed to document a thorough wound assessment, failed to follow physician orders, failed to ensure that treatment administration is not documented when not performed and/or failed to implement care plan interventions for three of three residents (R2, R3, R4) reviewed for wound care.

Inspectors wroteBased on interview and record review, the facility failed to have sufficient staffing on the weekend. This failure affects all 245 residents residing in the facility reviewed for lack of staff.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) ensure food items were labeled and dated per facility policy, b.) keep food storage areas clean, c.) conduct hand washing in between handling dirty and clean plate ware/equipment, d.) thaw frozen meat under running cold water. These failures have the potential to affect all 242 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 245 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents were treated with respect and dignity by not passing out meals to all residents sitting at a table at the same time. These failures affected 6 residents (R31, R36, R40, R129, R139, R205) reviewed during dining in a total sample of 35 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary services that are consistent with professional standards to prevent the development and worsening of pressure ulcers. The facility failed to a. follow the provider order in the prevention of pressure injury for one resident (R44), b. follow policy and manufacturer directions when adding multiple layers on low air loss mattresses for two residents (R212) and (R91) and c. provide adequate supervision for low air loss devices to prevent accidents for one resident (R158) out of a total sample of thirty-five residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (R221) resident had access to call light of six residents reviewed for call lights in a sample of 35 reviewed.

Inspectors wroteBased on observations, interviews and records review, the facility failed to protect one (R101) resident's personal and confidential information of 6 residents reviewed for patient information protection in a sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to initiate a new Level I screen for a resident with a known mental illness for one (R223) resident reviewed for Pre-admission Screening and Record Review (PASARR) in a sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician order policy for prescribed gastrostomy tube feeding rate. This failure affected one (R4) resident reviewed for tube feeding in a sample of 35. Findings Include: On 05/14/24 at 01:26 PM, observed R4 lying in bed with HOB/head of bed elevated, and tube feeding infusing. Observed 1.2-liter (L) bottle of Jevity 1.2 hung with label listing date (05/14/24) and hang time (9:00 AM). Observed tube feeding infusing at 55 milliliters (ml) per hour (hr.). On 05/14/24 at 01:57 PM, V15 (Registered Nurse) stated V15 knows R4 well and has taken care of R4 before. V15 stated V15 follows R4's tube feeding orders listed in R4's electronic health record (EHR) ordered by R4's physician. V15 stated R4 is NPO (nothing by mouth) and receives Jevity 1.2 at 55 ml/hr via gastrostomy tube. [...]

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow their policy on controlled drug count by failing to accurately count and reconcile controlled medication record/log for three (R220, R492, R211) of six residents in a sample of 35 reviewed.

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect residents from resident-to-resident physical abuse. This failure affects two (R1, R5) residents out of seven residents reviewed for abuse. As a result of this failure, R2 hit R1 in the face with a shoe on 02/28/2024 resulting in R1 sustaining a facial laceration, being sent to the hospital, and requiring four sutures; facility failed to protect R5 from physical abuse by R4.

Inspectors wroteBased on observations, interviews and review of records, the facility failed to protect a resident's right (R15) to be free from physical abuse and failed to address continuing abusive behaviors of a resident (R4). These failures affected 2 residents (R4 and R15) out of 5 residents (R4, R9, R10, R11, and R15) reviewed for abuse. These failures resulted to R4 requiring hospitalization for psychiatric evaluation and R15 being transferred to local hospital after sustaining skin tear on left eyebrow.

Inspectors wroteBased on interviews and records reviewed, the facility failed to report and initiate an investigation of an injury of unknown source in the time frame required resulting in the delay of the investigation. This failure affected 1 resident (R3) out of 15 residents reviewed.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to follow multiple policies related to the following: Failed to maintain ice free from outside leaks coming from sanitary source or exposed to unsanitary surface. Failed to prepare food free of contact to object that sanitation was not maintained. Failed to store fruits inside walk in cooler fruits that are without molds and discolorations to prevent possible serving to residents. Failed to label food in dry storage that are opened. Failed to follow FIFO (first-in first-out) policy on canned fruits in dry storage room These failures have the potential to affect 229 residents who is taking food by mouth in receiving quality dietary services.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to remove garbage in a safe and efficient manner per policy to prevent garbage from overflowing with lids to contain garbage in order to not be exposed near food. These failures have the potential to affect 229 residents who is taking food by mouth in receiving quality dietary services.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to place signs per policy for two residents (R168 and R176) who are in contact precautions for diagnosis of infectious disease. These failures have the potential to spread infection for all persons entering the room without taking proper precautions. This failure has the potential to affect all 234 residents.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to address maintenance issues with the ice machine that was exposed to leakage from an unclean source. These failures have the potential to affect 229 residents who is taking receiving ice use for daily consumption.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two medication carts were free of expired medications. This failure has the potential to effect 25 residents receiving medications from the medication cart on the 1st floor and R22 receiving insulin from the medication cart on the 3rd floor.

Inspectors wroteBased on observations, interviews and records review, the facility failed to ensure food served was palatable, attractive, and appetizing for four (R164, R145, R57, R155) residents reviewed for food quality in a sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their menu and provide a nutritionally equivalent product (due to making a food substitution change) for residents on mechanically altered diets and 2-gram Na (sodium) diets. This failure has the potential to affect all 16 residents receiving pureed diets, 29 residents receiving mechanical soft diets, 2 residents receiving 2 gm Na diets and 7 residents receiving 2 gm Na/low fat/low cholesterol diets of those reviewed for food and nutrition services. Findings Include: On 09/18/22 at 11:58 AM, the following items were observed being served on the tray line for lunch service: 1 breaded chicken patty, # 8 scoop mashed potatoes, 4 oz. broccoli, 3 oz. ground breaded chicken, #10 scoop pureed breaded chicken, #8 scoop pureed broccoli, 2 oz. chicken gravy. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure food was served in a sanitary manner for 5 residents (R7, R25, R36, R84, R176) receiving dessert served from the kitchen and beverages served on the second-floor unit.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store the ice scoop and wash the portable ice coolers for the residents residing on floors 2 through 5. This deficient practice has the potential to affect all 55 residents on 2nd floor, all 49 residents on the 3rd floor, all 57 residents on the 4th floor and all 56 residents on the 5th floor that receive ice from portable coolers on the unit of those reviewed for infection control.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain accurate code status orders that follow a resident's (R87) POLST (Physician Orders for Life-Sustaining Treatment) form and failed to remove a resident's (R108) hospital bracelet that was not consistent with the resident's code status for 2 of 35 residents reviewed for Advanced Directives.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to (a) assess the removal of a resident's (R219) urinary catheter as soon as possible, (b) provide a dignity bag for a resident (R219) and (c) keep a resident's (R108) urinary catheter bag off the floor for 2 of 3 residents reviewed for catheters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label an opened insulin vial for 1 (R166) out of 1 residents reviewed for insulin in a sample of 35 residents. Findings Include: On [DATE] at 11:10 AM, the 5th floor medication cart 2 was inspected with V21 (Licensed Practical Nurse). A 10ml vial of 70/30 insulin for R166 was stored in medication cart with no open date on the vial. On [DATE] at 11:10 AM, V21 (Licensed Practical Nurse) stated, insulin should have an open date written on the vial when it is opened. The open date lets you know when to discard the insulin. Insulin is only good for 28 days. Whoever opened this insulin must have forgot to put an open date on it. On [DATE] 11:25 AM, V3 (Director of Nursing) stated, insulin should be dated with an open date, so you know when to dispose of it. Insulin should be discarded 28 days after it is open. [...]

Inspectors wroteBased on observation, interviews and records review, the facility failed to provide dental services for one resident (R171) reviewed for dental care, in a sample of 35 residents.