Claru Deville Nursing Center

Inspectors wroteBased on interview and record review, the facility failed to demonstrate evidence of maintaining an ongoing effective, comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. This had the potential to affect all residents residing in the facility. The facility's census was 67. Review of the facility's policy titled, Quality Assessment and Assurance (QAA), reviewed 01/26/26, showed:- The facility is committed to ensuring high-quality care and continuous improvement in resident outcomes through a structured Quality Assessment and Assurance program. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program committee met at least quarterly with the required members present. This had the potential to affect all residents by limiting the facility's ability to identify and address quality of care and safety concerns. The facility's census was 67. Review of the facility's policy titled, Quality Assessment and Assurance (QAA), reviewed 01/26/26, showed:- This facility is committed to ensuring high-quality care and continuous improvement in resident outcomes through a structured QAA program. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to demonstrate measures used to minimize the risk of Legionella (a bacteria naturally found in freshwater that can cause serious lung infections, most common Legionnaires' disease, which is a severe form of pneumonia) and other opportunistic pathogens in the building water system, by not providing a documented water management program. This deficient practice had the potential to affect all residents, staff and visitors. The facility's census was 67. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or their representatives, in advance of the risks and benefits of proposed care, before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for four residents (Residents #4, #10, #27, and #46) out of 17 sampled residents. The facility's census was 67. Review of the facility's Management of Psychotropic Medications and Unnecessary Medications policy, dated 04/28/25, showed: - The use of psychotropic medications will be carefully monitored to prevent unnecessary usage and will be prescribed only when clinically indicated, with full consideration of the resident's preferences and rights; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents (Residents #10 and #66) out of two sampled residents who were discharged from Medicare Part A services with benefit days remaining and remained in the facility. The facility's census was 67. Review of the Form Instructions: [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment by failing to ensure the building was free from odors and adequate reusable dinnerware was available for the residents, which resulted in the use of disposable foam dishware. This affected one resident (Resident #53) out of 17 sampled residents and one resident (Resident #44) outside the sample. This had the potential to affect all residents. The facility's census was 67. The facility did not provide a policy regarding odors or the use of disposable dinnerware. 1. Observations on 04/21/26 at 12:14 P.M., 04/23/26 at 2:50 P.M., and 04/24/26 at 1:04 P.M., of the 600 Hall showed a strong odor of urine. 2. Observation of the test tray on 04/21/26 at 12:00 P.M., showed the tray included a foam bowl containing black-eyed peas. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital and failed to provide a copy of the bed hold policy upon transfer to the hospital for four residents (Residents #3, #10, #27, and #55) out of 17 sampled residents. The facility also failed to notify the ombudsman (a trained advocate who investigates and resolves complaints made by or on behalf of residents in nursing homes, assisted living, and other residential care facilities) of the transfers. The facility's census was 67. The facility did not provide a policy. 1. Review of Resident #3's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident's representative was informed in writing, of the daily bed hold rate; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plans with specific interventions to meet individual needs for two residents (Residents #12 and #21) out of 17 sampled residents. The facility's census was 67. Review of the facility's policy, dated 10/01/15, showed it is the policy of the facility to use the most current Center for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS-a standardized comprehensive assessment completed by facility staff) Resident Assessment Instrument (RAI) Manual, any published interim RAI manual errata documents, and applicable federal guidelines as the authoritative guide for completion of MDS, Care Area Assessment (CAAs-investigations triggered by the MDS), and resident care planning. 1. Review of Resident #12's medical record showed: - admission date of 09/01/25; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician's orders for two residents (Residents #1 and #75) out of 17 sampled residents. The facility's census was 67. Review of the facility's policy titled, Physician's Orders, undated, showed:- Each resident must be under the care of a licensed physician authorized to practice medicine in this state and must be seen by the physician at least every sixty days;- Physician's orders must be signed by the physician and dated when such order was signed;- Physician orders must be reviewed and renewed. 1. Review of Resident #1's medical record showed:- admission date of 12/27/23;- Diagnoses of chronic pain, tremor (involuntary movement), and fracture of left acetabulum (deep cup shaped socket where the upper part of the hip sits for the ball and socket hip joint). [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, and provide supportive interventions for three residents (Residents #12, #21, and #46) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of three sampled residents. The facility's census was 67. The facility did not provide a policy. 1. Review of Resident #12's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD and major depressive disorder (persistent low mood, loss of interest in pleasurable activities, and fatigue, lasting at least two weeks); - No trauma informed care assessment. Review of the resident's physician order sheet (POS), dated 04/24/26, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of three sampled Certified Nurse Aides (CNAs) received an annual performance review. The facility's census was 67. The facility did not provide a policy regarding CNA annual performance reviews.1. Review of CNA D's personnel file showed:- Hire date of 04/01/25;- No documentation of an annual performance review.2. Review of CNA E's personnel file showed:- Hire date of 04/07/25;- No documentation of an annual performance review.3. Review of CNA F's personnel file showed:- Hire date of 03/21/25;- No documentation of an annual performance review. During an interview on 04/24/26 at 12:30 P.M., the Director of Nursing (DON) said performance reviews have not been getting done, but they are going to start doing them. She said she was unsure of how often they will be done, maybe yearly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a safety and maintenance assessment for the use of a trapeze bar (a medical mobility device consisting of a triangular handle hanging from an overhead metal frame, attached to a bed or freestanding) for one resident (Resident #75) out of one sampled resident. The facility's census was 67. The facility did not provide a policy regarding the use and maintenance of a trapeze bar.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide at least twelve hours of nurse aide in-service education per year to include dementia care (care of a resident with an impaired ability to remember, think or make decisions), care of cognitively impaired residents and/or abuse/neglect training for three of the three sampled Certified Nurse Aides (CNAs). The facility's census was 67. The facility did not provide a policy regarding CNA in-service requirements.1. Review of CNA D's in-service record showed:- A hire date of 04/01/25;- A total of nine in-services, dated 12/10/25; no length of time provided for each in-service;- No documented abuse/neglect, dementia care or the care of cognitively impaired residents training.2. Review of CNA E's in-service record showed:- A hire date of 04/07/25;- A total of nine in-services, dated 12/10/25; [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide protective oversight for two residents (Resident #1 and #3) with psychiatric diagnoses and a history of self harm who resided on the secured behavioral unit. On 02/25/25, Resident #3, who had and had a history of ingesting batteries, swallowed two AA batteries, which resulted in transfer to the emergency room (ER) and a procedure to remove the battery. On 02/26/25 at 12:44 P.M., Resident #1 became agitated and made threats of self harm by swallowing items. Resident #1 was placed on 15 minute checks, continued to make self harm threats, and ingested two AA batteries at 3:49 P.M., which resulted in an ER transfer. The facility did not provide documentation or evidence the 15 minutes checks were completed for Resident #1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents on the secured behavioral unit from abuse through deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This deficiency affected three sampled residents (Resident #11, #61, and #68) on the secured behavioral unit, resulting in humiliation and embarrassment for those residents and back pain for Resident #68 from sleeping on a mattress on the floor and had the potential to affect all residents on the secured behavioral unit. The facility also failed to protect one resident's (Resident #11) right to be free from physical abuse when Certified Nurse Assistant (CNA) A physically forced Resident #11 to the ground and physically restrained Resident #11 while on the ground, making Resident #11 feel humiliated. The facility's census was 74. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure and promote an environment that promoted maintenance or enhancement of each resident's quality of life, recognizing each resident's rights, failed to protect and promote the rights of the resident, failed to allow the resident to exercise his or her rights as a resident of the facility without coercion, interference, discrimination, or reprisal from the facility, and failed to ensure the residents were able to exercise their rights as a resident of the facility and were free of restraints when 3 of 22 residents (Residents #11, #61 and #68) were placed in a secured unit without evaluation for appropriate placement and their resident rights were removed per the guardians' directions, based on a list of actions and consequences. The facility's census was 74. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for three sampled residents (Residents #11, #61 and #68) out of 22 residents who reside on the secured behavior unit. The facility failed to care plan resident specific interventions and did not assess the affect of the use of an actions/consequences list requested by the guardian. The facility did not develop a behavior plan or crisis intervention plan for residents as indicated by the pre-admission behavioral health screening. The unit enforced a program of negative consequences should a resident exhibit behaviors. The facility census was 74. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI, a program to improve the processes for the delivery of health care and quality of life for the residents) program in place with policies and protocols describing how the facility will identify and correct its own quality deficiencies. This deficient practice had the potential to affect all residents in the facility. The facility's census was 74. The facility did not provide a QAPI policy or any documentation related to a QAPI program. During an interview on 01/15/25 at 12:30 P.M., the Assistant Director of Nursing (ADON) said they don't have QAPI meetings. During an interview on 01/16/25 at 3:36 P.M., the Administrator said he has no QAPI policy or plan, nor does he have a list of the QAPI committee members. He knows he should be doing something more formal. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility's census was 74. The facility did not provide a QAPI policy or any documentation related to a QAPI program. During an interview on 01/15/25 at 12:30 P.M., the Assistant Director of Nursing (ADON) said they don't have QAPI meetings. During an interview on 01/16/25 at 3:36 P.M., the Administrator said he has no QAPI policy or plan. He knows he should be doing something more formal. They do have a daily stand up meeting. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee meetings with the required members. The facility's census was 74. The facility did not provide a QAPI policy or any documentation related to a QAPI program. During an interview on 01/15/25 at 12:30 P.M., the Assistant Director of Nursing (ADON) said they don't have QAPI meetings. During an interview on 01/16/25 at 3:36 P.M., the Administrator said he has no QAPI policy or plan, nor does he have a list of the QAPI committee members. He knows he should be doing something more formal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a risk management process specific to Legionnaires' disease (a severe type of pneumonia caused by the Legionella bacteria) which had the potential to affect all residents, staff, and the public. The facility failed to maintain infection control practices to prevent the development and transmission of infection during peri care (washing the genital and anal areas of the body) for one resident (Resident #23) out of one sampled resident. The facility failed to implement enhanced barrier precautions (EBP) during wound care for one resident (Resident #1) out of one sampled resident when the policy was not followed to ensure personal protective equipment (PPE) was available outside or near the rooms of those residents on EBP and proper PPE for EBP applied before and during care. The facility's census was 74. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain the highest practicable physical, mental, and psychosocial well-being for three sampled residents (Residents #11, #61 and #68) who resided on the secured behavior unit. This deficient practice had the potential to affect all 22 residents on the secured behavioral unit. The facility's census was 74. The facility did not provide any policies or procedures regarding secured behavior unit staffing needs, specialized training needed to work on the locked behavior unit, or criteria for admission to the locked behavior unit. The facility did not provide any mental health behavior training program for staff working on the secured behavioral unit. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASARR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder, to determine the level of care needed) for one resident (Resident #63) out of 18 sampled residents. The facility's census was 74. The facility did not provide a policy for PASARR. 1. Review of Resident #63's medical record showed: - An admission date of 03/10/23; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean bilevel positive airway pressure (BiPAP, a machine that pushes pressurized air into the lungs at distinct levels on inhalation and exhalation) and continuous positive air pressure (CPAP, a treatment for breathing issues that involves a machine delivering constant pressurized air through a mask) machines per the manufacturer's guidelines for two residents (Resident #39 and #46) out of two sampled residents. The facility's census was 74. Review of the facility's policy titled, Oxygen Administration, dated March 2015, showed: - Purpose, to administer oxygen to the resident when insufficient oxygen in being carried by the blood to the tissues; - At regular intervals, check and clean oxygen equipment, masks, tubing and cannulas; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent when medications were administered. There were 25 opportunities with three medication errors made, for an error rate of 12%. Out of six residents observed, this affected two residents (Resident #41 and #57) out of 18 sampled residents and one resident (Resident #53) outside the sample. The facility's census was 74. Review of the facility's policy titled, Diabetes Mellitus (a chronic metabolic disease that occurs when the body can't produce or use insulin properly), Control of, dated March 2015, showed: - Purpose, to assist the resident to establish a balance between diet, exercise and insulin (a hormone that regulates blood sugar levels by moving blood sugar into cells where it can be used for energy); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when two residents (Residents #1 and #2) were involved in a verbal and physical altercation, which resulted in both residents on the ground hitting each other. The facility's census was 74. The facility was notified of past non-compliance on 10/31/24. Facility staff immediately intervened, notified administration, separated the residents, and provided assessment and services to the involved residents. Staff were in-serviced on abuse and neglect prevention. The deficiency was corrected on 10/10/24. Review of the facility's policy titled, Abuse, undated, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to properly notify the resident and/or the resident's representative in writing of a facility-initiated transfer when three residents (Resident #1, #2 and #3) out of three sampled residents transferred to the hospital. The facility census was 68. Review of the facility's policy titled Discharge/Transfer of Resident, undated, showed: -discharge: To leave the facility without plans or intentions to return (i.e., discharge to go home, a lower level of care or another long-term care facility); -Transfer: To leave the facility with plans or intentions to return (i.e., transfer to an acute care facility for appropriate care); -To provide safe departure from the facility and to provide sufficient information for aftercare of the resident; -discharge: [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or legal representative of their bed hold policy at the time of transfer to the hospital for three residents (Resident #1, #2 and #3) out of three sampled residents. The facility's census was 68. Review of the facility's policy titled, Bed Hold Policy Guidelines, undated, showed: - This facility will notify all residents, and/or their representative of the bed hold policy guidelines. This notification shall be given: 1. Upon admission to the facility, 2. At the time of transfer to the hospital or leave; and 3. At the time of non-covered therapeutic leave; - If the resident or resident representative wants to hold the bed, a signed authorization of the Bed Hold Selection Notice must be obtained with each physician approved hospitalization or therapeutic leave of absence. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled for at least eight consecutive hours per day, seven days a week. This deficiency had the potential to affect all residents. The census was 68. The facility did not provide a RN coverage policy. Review of the Nursing Daily Staffing Sheets for 04/01/24 through 05/01/24 showed: - No RN scheduled for 04/13/24 through 04/14/24; - No RN scheduled for 04/17/24 through 04/18/24. An agency RN was scheduled for 04/18/24. He/she called in, and was not replaced by another RN; - No RN scheduled for 04/26/24 through 04/27/24. An agency RN was scheduled for 04/26/24. He/she called in, and was not replaced by another RN; - No RN scheduled for six out of 31 days. Review of the current staff list showed two RNs which included the DON. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when two residents (Residents #6 and #14), out of two sampled residents, transferred to the hospital. The facility census was 67. The facility did not provide a policy regarding hospital transfer notifications. 1. Review of Resident #6's medical record showed: - Resident transferred to the hospital for medical evaluation on 09/27/23 and readmitted to the facility on [DATE]; - No documentation of the written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. Review of Resident #14's medical record showed: - Resident transferred to the hospital for medical evaluation on 08/24/23 and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and family or legal representative of their bed hold policy at the time of transfer to the hospital for two residents (Resident #6 and #14) out of two sampled residents. The facility's census was 67. Review of the facility's policy titled, Discharge/Transfer of Resident, undated, showed: - Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Notice of transfer or discharge to be provided as necessary; - Bed hold forms to be provided as necessary. 1. Review of Resident #6's medical record showed: - Transferred and admitted to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the facility bed hold policy at the time of transfer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care plans with specific interventions to meet individual needs for one resident (Resident #40) out of six sampled residents, and one resident (Resident #48) outside the sample. The facility census was 67. Record review of the facility's policy titled, Care Plan Comprehensive, dated March 2015, showed: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -A well-developed care plan will be oriented to managing risk factors to the extent possible or indicating the limits of such interventions; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for the residents and staff by not removing miscellaneous items on top of overbed light fixtures. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 67. Review of the facility's policy titled, Environmental Safety and Health, dated May 2006, showed: - The Facility Safety and Health Committee with environmental safety in mind will work toward maintaining a safe work environment and control unsafe actions, and conduct periodic safety audits of specific areas of the workplace; - Each department will conduct a survey of their department every other month, and on the alternating month, the survey will be conducted by another department leader to be assigned by the Facility Safety and Health Committee Director; [...]