Clement Manor Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 (R59) of 1 sampled residents, received basic life support, including cardiopulmonary resuscitation (CPR), in a timely and effective manner. This deficient practice has the potential to affect 4 of 46 residents with full code status.*R59 was identified as a full code and staff did not immediately initiate CPR upon discovering R59 was pulseless and non-breathing. The facility's failure to provide basic life support for a resident with a full code status, created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on [DATE] at 11:36 AM. The immediate jeopardy was removed on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 2 (R9 and R23) of 4 residents reviewed for falls. *R9 experienced eleven falls since admission to the facility and R9's Falls plan of care was not revised after the falls to address the root causes of the fall. As a result of a fall, R9 sustained a right clavicle fracture and a left patella fracture. *R23 had a fall on 1/24/2026. The facility could not provide evidence that a post fall investigation was completed. R23's care plan was not updated post fall.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety. This practice had the potential to affect all 46 residents residing in the facility. *Equipment in the kitchen was not in clean, sanitary condition. Three prep stations had grease built-up on the front and back, legs of prep stations had dried food on them, crumbs in the crevices of the doors, splattered dried food on the front. The heater had red dried splattered food on it. The temp fryer had crumbs on the crevices on the back and the cords and plug ins are extremely caked with dried food and grease. The stove had dried food and grease on the front, crumbs in the crevices under the buttons. The convection oven and fryer had dried splattered food and grease. [...]

Inspectors wroteBased on interview and record review the facility did not ensure a thorough investigation into a Covid outbreak was conducted. This had the potential to affect all 46 residents. The facility had a Covid outbreak on 2/7/26. The line list documents by 2/7/26, three residents were diagnosed with Covid. The facility did not conduct and document an investigation into this outbreak.

Inspectors wroteBased on interview and record review the facility did not ensure 6 (R60, R39, R1, R40, R37 and R33) of 6 residents reviewed for receiving antibiotics had indications for use of antibiotics. The facility uses McGeer's Criteria to determine indications of possible infections. R60, R39, R1, R40, R9, R37 and R33 did not have the necessary symptoms to indicate an infection. The facility's former Medical Director-K was informed these residents did not have indications of infection based on the facility's standard of practice and continued to prescribe antibiotics for those residents.

Inspectors wroteBased on interview and record review, the facility did not ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (regarding R33) of 3 allegations reviewed. *R33 reported concerns of misappropriation that were not investigated thoroughly, no like resident interviews were conducted.

Inspectors wroteBased on observation, interview and record review the Facility did not develop and implement a comprehensive person-centered care plan to meet a resident's medical, and psychosocial needs for 1 (R8) of 13 residents reviewed. R8 is hard of hearing, R8 does not have a comprehensive care plan that addresses being hard of hearing and strategies to assist R8.

Inspectors wroteBased on interview and record review, the facility did not ensure residents received care in accordance with professional standards of practice following a fall for 2 (R9 and R23) of 4 residents reviewed for falls. *R9 did not have documented neurological checks completed after unwitnessed falls or falls with a head injury. *R23 had a fall on 1/24/2026. The facility could not provide evidence neurological checks were completed post fall.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R2) of 3 residents reviewed maintains acceptable parameters of nutritional status, such as body weight or desirable body weight range and electrolyte balance. R2 was documented to have a significant weight gain on 4/30/26 and 5/12/26 with no documentation indicating R2's provider or Registered Dietician (RD) was notified.

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that 1 (R7) out of 5 residents reviewed for unnecessary medications had their Pharmacist Drug regimen review/recommendations acted upon in a timely manner. R7's monthly pharmacy review recommendation was not acted upon. Evidenced by:Surveyor conducted a review of R7's monthly drug regimen reviews From January 2026- May 2026. On 1/19/26, the reviewing Pharmacist indicated there was an insignificant irregularity that was identified for R7 drug regimen. The recommendation documented, please verify frequency of vital checks. Appears that last BP (Blood Pressure) and pulse were done on 12/10/25, over one month now. On 5/14/26 at 2:00 PM, Surveyor was provided with a copy of the facility's response to the pharmacy recommendation. It was documented there was a gap in documents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the daily nursing staff posting contained all required information accurately. This deficient practice has the potential to affect all 46 Residents residing in the facility. The facility's nurse staff posting did not accurately reflect the correct number of staff members on each daily nurse staff schedule.

Inspectors wroteBased on interviews, record review, facility policy review, and review of the facility's investigation, the facility failed to ensure two residents (Resident (R)2 and R5) of nine residents reviewed for abuse, were free from physical abuse. R2 physically abused R5 on 09/04/25. R5 physically abused R2 on 10/30/25. This had the potential to cause emotional and/or physical harm to both R2 and R5.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to have a physician ordered medication available for administration for one of one resident (Resident (R) 5). The facility failed to decrease the order of Eliquis (blood thinner) when the physician ordered Paxlovid (an antiviral). The potential when administering Paxlovid in conjunction with Eliquis increased the risk for severe bleeding.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure 1 (R10) of 1 Resident reviewed for communication with the use of hearing aides, received proper treatment and assistive device to maintain R10's hearing abilities. Findings Include: R10 was admitted to the facility on [DATE] with diagnoses of Chronic Systolic Congestive Heart Failure, Chronic Kidney Disease, Stage 3, Anemia, , Nocturia, Dysphagia, and Unspecified Dementia. Surveyor reviewed R10's Quarterly Minimum Data Set (MDS) dated [DATE] which documents R10's Brief Interview for Mental Status (BIMS) score to be a 13 which indicates R10 is cognitively intact for daily decision making. R10's MDS also documents that R10 requires limited assistance of 1 for bed mobility, transfers, dressing, toileting, and hygiene. R10's MDS documents that R10 has hearing aides and hears with minimal difficulty. [...]

Inspectors wroteBased on record review and staff interview the facility did not ensure 1 (R28) of 5 Resident's drug regime reviewed was free from unnecessary medications. R28 receives an anticoagulant (Eliquis) in which the facility is not adequately monitoring and there is no care plan in place to address the use of the anticoagulant. Findings Include: Surveyor reviewed the Anticoagulant Monitoring policy and procedure last revised 9/2023 and notes the following applicable: .D. Monitoring for Signs and Symptoms of Bleeding 1. Residents on Warfarin/Eliquis/Pradaxa/Lovenox/Heparin/Xarelto/ASA or alike drug class, should be monitored for bruising, bleeding from gums during teeth brushing, blood in the stool, sudden onset of confusion that may indicate bleeding in the brain, or recent changes in breathing patterns or sounds that may indicate bleeding in the lungs. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not always ensure that 1 (R342) of 5 residents reviewed were given psychotropic medications with adequate monitoring. * R342 was administered scheduled Sertraline (Zoloft- antidepressant) with no identified targeted behaviors for staff to be monitoring in order to determine the effectiveness of the medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure coordination of care and the hospice communication process was followed for 1 Resident (R25) of 2 Residents reviewed for hospice services. R25's hospice care plan was not integrated in the facility care plan or easily identifiable by facility staff in R25's hospice binder. R25's hospice binder did not include the agreed upon hospice documentation of interdisciplinary progress notes (IDT), updated plan of care, schedule of visits. Further, R25's recertification for hospice benefits ended as of 3/25/23 and R25's hospice documentation did not reflect the recertification had been renewed. Findings Include: Surveyor reviewed the facility's Hospice Coordination of Services policy and procedure last reviewed on 9/11/23 and notes the following applicable: .Policy: [...]