Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clara Manor Nursing Home during CMS and state inspections, most recent first.
A resident with a history of cerebral infarction, anxiety, and depression was physically abused by a CMT, resulting in facial injuries and significant distress. Despite the resident reporting the incident to two staff members, the CMT was allowed to continue working the remainder of their shift, contrary to facility policy requiring immediate protection and suspension of staff involved in abuse allegations. Staff interviews and documentation confirmed the delay in removing the CMT, and the resident's injuries were observed and documented by clinical staff.
A resident with cognitive intactness and multiple diagnoses reported being physically abused by a CMT, resulting in visible facial injuries. The incident was disclosed to an LPN, the AIT, and the Administrator, and the facility's investigation confirmed the abuse. Despite facility policy requiring timely reporting of abuse to law enforcement, neither the Administrator nor the DON notified authorities.
The facility failed to ensure RN coverage for eight consecutive hours per day, seven days per week. Staffing sheets showed no RN scheduled for eight consecutive hours on multiple days in May 2025, and the Administrator stated the facility should have RN coverage 8 hours a day, 7 days a week. The facility also did not provide the requested nurse staffing policy.
Unsafe food storage, poor kitchen sanitation, and hand hygiene failures were observed in the dietary area. Staff left multiple food items unlabeled or undated, stored expired and improperly placed items, and worked around dirty refrigerators, mold-like buildup, grime, dust, and uncovered food. Staff were also observed entering the kitchen without washing hands, changing gloves without handwashing, eating in the kitchen, handling food with gloved hands after contact with other surfaces, and working in a soiled shirt. Daily temp logs for refrigeration were not maintained.
Failure to inform residents of the risks and benefits of psychotropic medications. Four residents had antipsychotic, antidepressant, or anti-anxiety meds ordered, but the chart lacked documentation of informed consent. One cognitively intact resident also said he/she did not recall being counseled on the meds. The Administrator stated there was no process for obtaining informed consent for psychotropic, anti-anxiety, or antidepressant medications.
Homelike Environment Not Maintained in Dining Areas and Hallways: Residents were not provided basic dining items such as spoons, napkins, and consistent condiments, and staff did not ask residents what they wanted to eat before serving meals. Observations showed sandwiches served in plastic bags and staff sitting in the dining room during meals while medication administration occurred at the table. In the hallways, facility cat litter boxes were not properly maintained, and residents reported strong unpleasant odors; an observation confirmed an empty litter box with a cat defecating in it and odor spreading through the area.
Expired and unlabeled medications were found in medication carts and storage areas, including stock meds that were unsealed but not dated, expired items in carts and a refrigerator, and an expired emergency kit containing insulin and suppositories. Staff also found a resident’s inhaler labeled only on the box, not the inhaler itself, and two opened insulin pens without open dates. Facility policy required stock meds to be dated when opened, insulin to be dated upon opening, and outdated drugs to be removed from stock.
Infection control failures occurred when staff did not place proper EBP signage and supply boxes for two residents with indwelling catheters, despite care plans and orders requiring EBP. In a separate event, a CMT walked in the hall with gloved hands, gave insulin to one resident, then used the same gloves to handle the med cart, review MARs, and administer meds to another resident without washing hands or changing gloves. Staff and the Administrator stated that gloves should be changed and hands washed between residents and that staff should not walk in the hall with gloved hands.
A facility failed to post the State Survey Agency contact information for residents and others who wanted to file complaints. During observation, no complaint information or state phone number was posted, and interviewed residents said they did not know where to find it; one resident said the only way to contact the state was to look it up online, while another thought it had been in the private phone room. The Administrator said the number had been posted there previously but was taken down when the room was painted.
Survey Results Not Available for Resident Review: The facility failed to make the most recent State Survey Inspection results available for resident review. A resident who was cognitively intact and another resident both said they did not know where the state survey book was located, and observation showed no posted signs on any floor directing residents to it. The Administrator said the book used to be at the front desk but did not know where it was currently located.
Unauthorized Smoking in Resident Bathroom: A cognitively intact resident with multiple psychiatric and medical diagnoses was found smoking in a roommate’s bathroom instead of the designated smoking area. The roommate reported repeated bathroom smoking and fear that a fire could start, and surveyors observed a strong cigarette smoke odor from the bathroom. Staff and the resident confirmed that smoking in rooms and bathrooms was not allowed, yet the resident said he/she sometimes smoked in the bathroom because the outside smoking area was too far away.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with a history of psychiatric disorders and behavioral issues physically assaulted another resident, causing facial swelling and pain. Multiple residents and staff reported ongoing threats and paranoid behavior from the aggressor prior to the incident. Despite these warnings and documented risks, staff interventions were limited to verbal redirection and separation, which did not prevent the assault. The facility did not provide an abuse/neglect policy when requested, and concerns about the aggressor's behavior had been reported but not effectively addressed.
A resident with a history of serious mental illness and escalating behavioral symptoms, including aggression and paranoia, physically assaulted another resident after months of unaddressed and increasing behaviors. Despite repeated reports from staff and residents, the care plan was not updated with appropriate interventions, and recommendations from psychiatric and psychological providers were not implemented. Staff responses were inconsistent, and facility leadership was unaware of the severity of the situation until police intervention was required.
A resident with a history of mental health issues and violent behavior hit another resident in the face, causing swelling and pain. Despite previous reports of the aggressive resident's behavior, the facility failed to implement adequate monitoring or preventive measures. The incident escalated to police involvement, highlighting deficiencies in the facility's abuse prevention and resident safety protocols.
A resident with a history of mental illness and substance abuse exhibited escalating aggressive and paranoid behaviors, culminating in a physical assault on another resident. Despite these behaviors, the resident's care plan was not updated to address safety concerns or provide appropriate interventions. Staff failed to document or communicate the resident's worsening condition, leading to inadequate management of the situation.
The facility failed to ensure the Dietary Manager (DM) met the qualifications for a Certified Dietary Manager (CDM). The DM, hired without the necessary certification or experience, confirmed that the facility had not assisted in obtaining the required qualifications. The Administrator was aware of the DM's lack of qualifications but had not taken further action. This deficiency potentially affected all 89 residents.
The facility failed to follow the planned menu on three occasions, affecting all residents. On two separate days, residents did not receive the meals listed on the menu due to time constraints and ingredient availability. Instead of the planned meals, substitutions were made, such as serving orange ice cream instead of peach crisp and sandwiches instead of the planned entrees.
The facility did not have a certified Infection Preventionist (IP) employed, as required by their policy, which mandates completion of CDC TRAIN programs. The Administrator had not finished the necessary course, and both an LPN and the DON confirmed the absence of an IP since August, affecting the infection prevention and control program for 89 residents.
The facility failed to control a roach infestation affecting the kitchen, dining room, and resident rooms. Observations revealed roaches in various locations, including under the dishwasher and in food storage areas. Staff interviews indicated cleaning challenges and insufficient pest control measures. A resident confirmed seeing roaches in their room, and the Health Inspector noted widespread infestation during a recent visit.
The facility failed to provide the required annual 12 hours of in-service training for CNAs and did not maintain records of training sessions. Interviews revealed a lack of documentation and uncertainty about the number and topics of in-services held. The DON admitted to conducting only eight to nine in-services throughout the year, none of which were documented, and there was no set schedule for observing staff competencies.
The facility did not maintain a sufficient bond amount for resident personal funds, as the bond was $150,000.00 instead of the required $186,000.00 based on the average monthly balance. This affected 56 residents who entrusted the facility with managing their trust accounts. The bookkeeper acknowledged the oversight and lack of a process to monitor the average monthly balance.
The facility failed to maintain a clean environment, with food crumbs and roaches observed in the dining room and dust buildup in restroom vents and fans in multiple resident rooms. The Dietary Manager and Maintenance Director acknowledged the issues, affecting at least 55 residents.
The facility failed to prevent medications from being left at the bedside for three residents, despite lacking physician orders for self-administration. Observations revealed medications unattended in residents' rooms, and staff interviews confirmed this practice, which contradicted facility policy. The Administrator and DON were aware of the issue and had provided staff education on proper medication administration.
The facility failed to maintain a system to ensure all staff had current CPR certifications and that certified staff were available on all shifts, potentially affecting 80 residents requiring CPR. The Administrator admitted to not having a system to track certifications, and staff interviews revealed uncertainty about their certification status.
A facility failed to maintain a resident's nutritional status, resulting in significant weight loss due to inconsistent implementation of physician orders for weekly weights and health shakes. The resident, who was severely cognitively impaired and required substantial assistance with eating, experienced a 7.05% weight loss over several months. Interviews revealed a lack of awareness and documentation by staff, and the newly hired RD was not fully informed of the resident's dietary needs.
The facility failed to maintain sanitary conditions for respiratory equipment for three residents, including improper storage and infrequent cleaning of nebulizer pipes, CPAP masks, and oxygen tubing. Residents reported irregular maintenance, and staff interviews revealed inconsistencies in following cleaning protocols.
The facility failed to post nurse staffing information correctly and accessibly, with sheets often placed in hard-to-reach locations and lacking total hours worked per discipline. Staff interviews confirmed the absence of required details, and the DON acknowledged the deficiency.
The facility failed to ensure proper storage and handling of medications, with issues including lack of temperature logs for medication refrigerators, wet insulin boxes, expired medications, and unclean sinks in medication rooms. Staff interviews revealed confusion over responsibilities for checking refrigerator temperatures and removing expired medications.
The facility failed to maintain proper food safety and hygiene standards, with issues such as a dietary aide's hair not fully restrained, improper storage of jelly, and significant cleanliness lapses in the kitchen. Observations revealed grime under the dishwasher, food buildup on toaster knobs, and dust on fan vent covers, indicating a lack of regular cleaning. Interviews with staff confirmed these oversights, potentially affecting all residents consuming food from the kitchen.
The facility failed to follow TB screening policies for residents and employees, did not sanitize glucometers between uses, and lacked Enhanced Barrier Precautions (EBP) for residents requiring high-contact care. Staff were not educated on EBP, and insulin pens were not sanitized before use, indicating broader infection control issues.
The facility failed to offer and document influenza and pneumococcal vaccines for several residents, as required by their policy. A resident with severe cognitive impairment did not have records of receiving or declining vaccines, and two other residents were not offered vaccines upon admission. Staff interviews revealed inconsistencies in vaccine consent and documentation processes, leading to deficiencies in immunization practices.
The facility failed to offer, administer, or document the 2024-2025 COVID-19 vaccine for two residents. One resident, severely cognitively impaired, had no record of the vaccine being offered or administered, while another resident with intact cognition had no documentation of the vaccine being offered or declined upon admission. Staff interviews revealed a lack of time and delegation of responsibilities, with no COVID-19 vaccine policy available for review.
The facility's call system on the 2nd floor was not audible at the nurse's station, affecting 46 residents. Observations showed that call lights in resident rooms and bathing areas were not heard, confirmed by staff interviews. The issue was linked to the panel's volume being too low due to an override from a stairwell door activation.
The facility failed to ensure cleanliness and safety, with a heavy dust buildup under vending machines in the second-floor dining room and a loose threshold at the carport entrance posing a tripping hazard. The Maintenance Director noted the difficulty in cleaning under the machines and acknowledged the threshold issue had persisted for weeks, affecting residents and staff.
A resident who was legally blind and cognitively impaired did not receive dignified feeding assistance. The CNA stood over the resident, failed to prevent spills, and did not offer cleaning assistance. Staff interviews revealed a lack of training and monitoring on feeding assistance, with the DON acknowledging irregular in-services and no set process for feeding residents.
The facility failed to conduct required Criminal Background Checks (CBC) and Employee Disqualification List (EDL) checks for three employees and did not maintain necessary records for two employees. Employee D was hired using outdated checks from another facility, and files for Employees J and K were missing, with no evidence of completed checks. This deficiency highlights lapses in the facility's hiring and record-keeping processes.
A resident with a history of mental health and substance abuse issues was improperly discharged from an LTC facility due to violent behavior. The discharge notice incorrectly stated a transfer to another facility, but the resident was taken to a hospital instead. The facility failed to follow its discharge policy, lacked a physician's order, and provided incorrect discharge documentation. The Ombudsman filed an appeal due to these deficiencies.
The facility failed to notify two residents and their representatives of hospital transfers, and did not provide the Ombudsman with required notifications. Staff interviews confirmed the facility's non-compliance with its own policies regarding discharge notifications and communication with the Ombudsman.
A facility failed to accurately complete the MDS for a resident, leading to an inaccurate care plan. The resident, who was severely cognitively impaired and legally blind, had bed rails that were not documented in the MDS. Staff provided conflicting information about the presence and purpose of the bed rails, and there was no documented assessment for them in the resident's medical chart.
The facility failed to review and revise a resident's care plan regarding bed rails, despite observations showing their use. Staff interviews revealed inconsistencies in awareness of the resident's use of bed rails or positioning bars. Additionally, the facility inaccurately dated another resident's care plan eight days post-discharge, with no prior documentation. The facility's care planning policy was not followed, leading to these deficiencies.
The facility failed to enforce smoking policies, with staff and residents smoking in prohibited areas. Two residents, one with a history of substance abuse and another with cognitive impairments, were found smoking in their rooms. Staff were observed smoking outside designated areas, and monitoring of residents was inconsistent, leading to continued non-compliance.
A facility failed to maintain proper communication with a dialysis center for a resident requiring dialysis. Only six out of 20 required communication forms were present, and three were undated. Staff interviews revealed that nurses were responsible for sending and retrieving these forms, but failed to consistently do so, leading to incomplete documentation of the resident's dialysis treatment details.
A facility failed to follow its Restraint Policy by not assessing or documenting the use of bed rails for a resident who was legally blind and severely cognitively impaired. The resident's care plan and medical records lacked any indication of bed rail use, and staff interviews revealed confusion about whether the resident had bed rails or a positioning bar. The resident's guardian was not informed about the use of such equipment, indicating a communication gap.
The facility failed to label and date foods stored in the resident use refrigerator, as required by policy. Observations revealed expired items and unlabeled food packages, potentially affecting at least three residents. An LPN was unsure of the responsibility for checking and discarding items, highlighting a lapse in adherence to food storage protocols.
The facility failed to keep the outdoor dumpster lids closed, as observed on multiple occasions. Despite expectations from dietary staff for the lids to be closed after trash disposal, observations on two consecutive days showed the lids remained open. Interviews with dietary staff confirmed the expectation for lids to be closed, highlighting a lapse in adherence to procedures.
A facility failed to ensure a resident's care plan was accurate by dating it eight days after the resident's discharge. The resident was admitted, discharged to a hospital, and later informed the facility of staying with a family member. Despite this, the care plan was initiated post-discharge, contrary to the facility's policy requiring timely completion and review. The DON and Administrator confirmed the care plan should not have been completed after discharge.
A resident with a history of alcohol and substance abuse physically assaulted two other residents in separate incidents, causing injuries that required medical attention. Despite the facility's policy to prevent abuse, staff failed to intervene or report the incidents adequately. The Director of Nursing and Administrator acknowledged the expectation for staff to protect residents, but the Administrator questioned the abuse conclusion due to lack of witnesses and alcohol involvement.
The facility failed to report two incidents of resident-to-resident abuse. In one case, a resident was hit in the mouth by another, causing a cut, and in another, a resident was hit, resulting in cheek lacerations. Despite documentation and communication among staff, these incidents were not reported to the DON or Administrator as required by the facility's policy. The Administrator questioned the nature of the incidents due to lack of witnesses and alcohol presence, leading to a failure to report to the state agency.
A resident was hit by another resident, resulting in a cut lip, but the facility failed to investigate the incident as required by their policy. Staff interviews revealed communication breakdowns, with an LPN not notifying the necessary parties and the DON and Administrator being unaware of the incident, leading to no investigation being conducted.
Failure to Immediately Remove Staff After Resident Abuse Allegation
Penalty
Summary
A deficiency occurred when a certified medication technician (CMT) physically abused a resident by placing the palm of their hand over the resident's mouth and squeezing hard, resulting in a scratch on the right cheek and a circular bruise on the left cheek. The resident, who was cognitively intact and used a wheelchair, reported feeling extremely frightened during the incident. The resident had a medical history including cerebral infarction, anxiety, and depression. The incident was witnessed by other residents, and the physical injuries were observed and documented by staff. Despite the resident reporting the abuse to two staff members, the facility failed to immediately protect the resident by allowing the CMT to continue working their shift until later that evening. The facility's policy required immediate protection of suspected victims and immediate suspension or removal of employees involved in abuse allegations. However, the CMT was not suspended until the following day, after the administrator was notified and further investigation took place. Multiple interviews confirmed that the CMT remained on duty after the allegation was reported, and staff were unclear about the required procedures for handling abuse allegations. Documentation and interviews revealed that the resident's injuries were consistent with the reported abuse, and the resident expressed fear of retaliation, initially hesitating to report the incident. Staff statements indicated confusion about the appropriate response, with the administrator and director of nursing acknowledging that the CMT should have been removed from duty immediately. The delay in removing the CMT from the facility after the abuse was reported constituted a failure to protect the resident from further potential harm.
Failure to Report Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to report an allegation of abuse to local law enforcement as required by its own policies. A cognitively intact resident with a history of cerebral infarction, anxiety, and depression reported that a Certified Medication Technician (CMT) forcefully grabbed their face and pushed them down the hall after the resident was seen looking for cigarettes on an unlocked medication cart. The resident sustained visible injuries, including a scratch and a bruise on the face, which were observed by staff. The resident disclosed the incident to an LPN, the Administrator in Training (AIT), and the Administrator, expressing fear of further retaliation from the CMT. The facility's investigation confirmed the resident's account, and the Administrator acknowledged that abuse had occurred. Despite this, the Administrator and Director of Nursing (DON) did not notify law enforcement of the incident, contrary to the facility's written policies that require timely reporting of suspected abuse to authorities. The CMT was instructed to leave the facility following the report, but law enforcement was not contacted at any point during or after the investigation.
RN Coverage Not Maintained as Required
Penalty
Summary
The facility failed to ensure it employed a Registered Nurse (RN) for eight consecutive hours per day, seven days per week. The facility census was 88, and it did not provide the requested nurse staffing policy. Review of the staffing sheets for May 2025 showed no RN scheduled for eight consecutive hours on 05/02, 05/10, 05/11, 05/22, and 05/23. During an interview on 10/17/2025 at 02:40 P.M., the Administrator said the facility should have RN coverage eight hours a day, seven days a week.
Unsafe Food Storage, Poor Kitchen Sanitation, and Hand Hygiene Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food service standards. During kitchen observations, surveyors found multiple food items in refrigerators and dry storage without required labels, dates, or use-by dates, including juice containers, sandwiches, cheese slices, tartar sauce, cocktail sauce, soy milk that had expired in June 2025, sliced turkey, soup, flour, sugar, corn meal, gelatin, gravy mix, and cane sugar. A case of nutritional chocolate shake was stored on the floor of the walk-in freezer, and the walk-in refrigerator had a black mold-like substance covering a 2' by 2' area on the back wall. The stand-up refrigerator near the ice machine had grease and food stains, and the refrigerator near the microwave and bread toaster had heavy oily grime, rust, and food stains. The kitchen environment was also observed to be unclean and not maintained in sanitary condition. Surveyors noted heavy dirt on baseboards and tiles near the steam line, a broken corner tile with exposed wall area, heavy dirt and oily grime under the sink area, grease streaks on the overhead grill area, food debris and crumbs on steam line lids, a stove top with baked-on burnt food encrusted on all six burners, and three ceiling tiles over the food preparation area with hanging dust. An industrial fan with visible dust was blowing directly onto uncovered desserts, and breakfast items including sausage links and fried eggs were left uncovered on kitchen tables after the meal had ended. Staff failed to follow hand hygiene and personal cleanliness standards. On one observation, there was no hand soap at the kitchen handwashing station. A non-kitchen staff member entered the kitchen, used the ice scoop, and did not wash hands. A dietary aide returned from dumping trash and did not wash hands, and later left the kitchen to the outside trash area, returned to work in the dishwashing area without washing hands, and then helped stage desserts. Another dietary aide was observed eating in the kitchen, changing gloves without washing hands, and handling food trays and food with gloved hands after touching another staff member. A dietary aide was also observed wearing a soiled shirt while filling food trays. Temperature monitoring records for the stand-up refrigerator and freezer showed the last recorded temperatures were on 10/13/25, with no temperatures recorded on 10/14 through 10/16/25, despite staff stating temperatures should be taken daily.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that four sampled residents were fully informed, or that their representatives were informed, of the risks and benefits of physician-ordered psychotropic medications. Resident #2 had severe cognitive impairment and diagnoses including anxiety disorder, depression, bipolar disorder, and psychotic disorder; the record showed Abilify 10 mg daily for delusions was started, but there was no documentation of informed consent for antipsychotic use. Resident #6 had moderate cognitive impairment and diagnoses including depression and schizophrenia; the record showed quetiapine fumarate 200 mg at bedtime for mood disorder, with no documentation of informed consent for antipsychotic use. Resident #8 was cognitively intact and had diagnoses including depression; the record showed buspirone 15 mg three times daily for anxiety disorder, bupropion HCL ER 150 mg daily for depressive disorder, and citalopram 40 mg daily for major depressive disorder, but there was no documentation of informed consent for anti-anxiety or antidepressant medications, and the resident stated he/she did not recall being counseled on the risks and benefits of taking those medications. Resident #12 had severe cognitive impairment and diagnoses including non-Alzheimer's dementia, depression, and psychotic disorder; the record showed Seroquel 25 mg daily for depression and sertraline 50 mg daily for major depressive disorder, with no documentation of informed consent for antipsychotic or antidepressant medications. The Administrator stated there was currently no process for obtaining informed consent from residents for the use of psychotropic, anti-anxiety, or antidepressant medications.
Homelike Environment Not Maintained in Dining Areas and Hallways
Penalty
Summary
The facility failed to provide a homelike environment in the dining room when residents were not given basic dining items and choices during meals. During observations, the dining room had self-serve coffee and water stations but no napkins and no spoons available for residents to stir beverages. Condiment baskets were inconsistent from table to table, and some tables had items such as salt, pepper, saccharin, or jelly but lacked sugar, creamer, butter, or other condiments that matched the meal being served. Residents reported that they had to ask staff for spoons or napkins, that menu choices were not offered before meals, and that meals were served on trays like a cafeteria rather than in a home-like manner. One resident said substitute meals were often peanut butter and jelly sandwiches served in plastic bags. The dining observations also showed staff behavior that did not support a homelike dining experience. An LPN and a CMT were observed sitting in the back of the dining room during the meal, with the CMT administering medications as needed at the table where he or she was sitting. The LPN stated that residents were not asked if they wanted something else to eat even if they barely touched their meal, and that residents should call out if they wanted something different. The Administrator stated that condiments should be on each tray, plastic ware should be available, extra napkins should be on the table, and sandwiches should not be served in plastic bags. The facility also failed to maintain a homelike environment in the resident hallways because facility cat litter boxes were not properly overseen. One cognitively intact resident with cancer, atrial fibrillation, heart disease, heart failure, hypertension, GERD, kidney disease, diabetes, anxiety, depression, and epilepsy reported that litter boxes should be filled with cat litter and that the smell was horrible when they were missing litter. Another cognitively intact resident with hypertension, kidney disease, depression, and anxiety said the litter boxes were unsightly, unsanitary, and smelled bad. During hallway observation, a litter box at the end of the south hall was empty, a facility cat defecated in it, and a strong odor was observed permeating the area.
Expired and Unlabeled Medications Found in Carts and Medication Storage
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored according to accepted professional principles. During observations on the two hall medication carts and in the medication room, surveyors found multiple stock medications that were unsealed but had no date written when opened, including stool softener, B12 vitamin, two bottles of geri-tussin, antacid tablets, milk of magnesia, and zinc. Surveyors also found expired medications in the carts and refrigerator, including artificial tears, glucagon, and an expired emergency kit that contained Lantus insulin, Aspart insulin, and suppositories. Staff acknowledged that expired medications were present and that some items were supposed to be replaced or removed, but the expired items remained available in the carts and refrigerator at the time of observation. The facility also failed to label a resident’s inhaler with the resident’s name and failed to date opened insulin pens for two residents. One resident’s Symbicort inhaler had the resident’s name on the box only, not on the inhaler itself, and the CMT stated the inhaler should have been labeled with the resident’s name. Two insulin pens, one Lantus pen and one Lispro pen, were opened but had no open date written on the tags. The LPN stated that insulin pens are normally dated when opened, but these pens were not dated at the time they were observed. Facility policies reviewed by surveyors stated that stock medications should be labeled with the appropriate date and initials, insulin should be labeled with a date and initials upon opening, and outdated or deteriorated drugs should be immediately withdrawn from stock. The Administrator acknowledged that expired medications should not have been in the carts or refrigerator, that the emergency kit had been told to be destroyed, and that insulin pens, stock medications, and resident inhalers should have been properly dated or labeled.
Infection Control Failures With EBP and Hand Hygiene
Penalty
Summary
The facility failed to provide infection prevention and control measures when staff did not use proper Enhanced Barrier Precautions (EBP) signage for two residents with indwelling medical devices. Resident #42 had intact cognition, required substantial assistance with transfers, toileting, showers, dressing, and personal hygiene, and had a suprapubic catheter related to neurogenic bladder. Resident #85 had intact cognition, used a wheelchair, was independent with ADLs, and had an indwelling Foley catheter related to neurogenic bladder. Both residents had care plans and physician orders indicating EBP for the presence of indwelling medical devices, yet observations showed no EBP sign or supply box on or near either resident’s door at first, and staff interviews confirmed the signs and supply boxes were expected for residents with catheters. The facility also failed to ensure hand hygiene and glove use were performed correctly during medication administration. During observation, CMT A walked in the hall with gloved hands, administered insulin to Resident #79, and did not remove gloves or wash hands before or after the injection. CMT A then used the same gloves to handle the medication cart, prepare medications, review MARs, and administer medications to Resident #1 without changing gloves or washing hands. Resident #79 had no cognitive impairment, was independent with ADLs, and had schizophrenia, PTSD, and diabetes; Resident #1 had intact cognition, substantial ADL assistance needs, and diagnoses including schizophrenia, high blood pressure, and diabetes. Interviews with staff and the Administrator confirmed the expected practice was to change gloves and wash hands between residents and not to walk in the hall with gloved hands. The facility’s hand washing policy required proper hand washing before, after, and between resident care, including medication administration. The observations and interviews showed that these infection control practices were not followed during care for the four sampled residents.
State Survey Agency Contact Information Not Posted
Penalty
Summary
The facility failed to protect resident rights when it did not post the State Survey Agency contact information for residents and others who wanted to file a complaint. The facility census was 88, and review of the facility’s Resident Rights-Dignity and Privacy policy showed that all residents have the right to complain and be heard and have free access to any representative of the state or federal government. During observation of the facility, there was no posted information regarding the state telephone number or how residents could file a complaint. Residents interviewed said they did not know where to find the state contact information. One cognitively intact resident with diagnoses including diabetes, cerebral palsy, anxiety disorder, bipolar disorder, and depression said the only way to contact the state was to look up the number online and did not recall it being posted anywhere in the building. Another resident said he or she did not know where the state phone number was posted to make a complaint. A third cognitively intact resident with diagnoses including cancer, atrial fibrillation, heart disease, heart failure, hypertension, GERD, kidney disease, diabetes, anxiety disorder, depression, and epilepsy thought the number was in the private telephone room used by residents and did not recall seeing it anywhere else. The Administrator said the number used to be posted in the private telephone room but must have been taken down when the room was painted a few months ago.
Survey Results Not Available for Resident Review
Penalty
Summary
The facility failed to protect residents’ rights by not providing access to the most recent State Survey Inspection results for resident review. The facility’s undated Resident Rights-Dignity and Privacy Policy stated that all residents have the right to examine facility inspection results, including plans of correction, but observation and interviews showed the survey book was not available where residents could view it. Resident #86 stated during interview that he/she had not seen the state survey book and did not know where it was supposed to be kept. Resident #13, whose annual MDS showed he/she was cognitively intact and had diagnoses including cancer, atrial fibrillation, heart disease, heart failure, hypertension, GERD, kidney disease, diabetes, anxiety disorder, depression, and epilepsy, also stated not knowing where the state survey book was located. Observation of the facility showed no posted signs on the ground floor, 1st floor, or 2nd floor indicating where residents could review the state survey book. The Administrator stated the book used to be at the front desk for residents to review but did not know where it was currently located.
Unauthorized Smoking in Resident Bathroom
Penalty
Summary
The facility failed to ensure a resident remained free from smoke and fire hazards when a roommate was found smoking in an unauthorized location in the room bathroom. Resident #77 was cognitively intact and had diagnoses including GERD, thyroid disorder, epilepsy, anxiety disorder, bipolar disorder, schizophrenia, PTSD, and psychotic disorder. During interview, Resident #77 stated that Resident #37 smoked in the bathroom multiple times during the week and that it made the resident nervous and scared because the roommate might start a fire in the room. Observation later showed a strong smell of cigarette smoke coming from the resident's bathroom. Resident #37 was cognitively intact and had diagnoses including hypertension, hip fracture, stroke, and anxiety disorder. The care plan stated the resident could smoke unsupervised and should be instructed about smoking risks and hazards, with staff to notify the charge nurse if smoking policy was violated. However, the resident told surveyors that he/she sometimes smoked in the bathroom because it was too far to walk to the outside smoking area. Observation also showed the resident outside the room with a pack of cigarettes in the pocket. Facility staff stated residents were not allowed to smoke in their rooms or inside the facility except for the designated enclosed smoking area, and that smoking in a room or bathroom would be a fire and safety hazard.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. On the evening of 1/10/25, one resident willfully struck another resident in the face, resulting in swelling and pain. The incident was witnessed by other residents, who reported that the aggressor had a history of threatening and violent behavior, including accusations that others were taking his belongings. Staff and residents described ongoing verbal altercations and escalating behaviors prior to the physical assault. The resident who committed the abuse had diagnoses including major depressive disorder, psychoactive substance abuse, and generalized anxiety disorder, and was prescribed multiple psychotropic medications. The care plan for this resident noted a risk for increased behaviors and directed staff to monitor episodes and attempt to determine underlying causes. Despite these documented risks and previous behavioral incidents, staff actions included verbal redirection and separation of the residents, but did not prevent the physical altercation. The aggressor was ultimately removed from the facility by police after further violent behavior. The resident who was assaulted had a history of schizophrenia, major depressive disorder, and chronic pain. After the incident, the resident reported swelling and pain, requested and received pain medication and an ice pack, and declined hospital care. Multiple residents and staff confirmed that the aggressor had exhibited paranoid and threatening behaviors prior to the incident, and some residents expressed fear of the individual. The facility failed to provide an abuse/neglect policy when requested, and staff interviews indicated that concerns about the aggressor's behavior had been reported but not effectively addressed.
Failure to Provide Effective Behavioral Health Interventions Resulting in Resident Assault
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of serious mental illness, including major depressive disorder, schizophrenia, and substance abuse. Despite multiple documented episodes of aggression, paranoia, and hallucinations, the resident's care plan was not updated to reflect new or escalating behaviors, nor were appropriate interventions such as behavior modification strategies, 1:1 monitoring, or safety measures for other residents implemented. The resident exhibited increasing agitation, paranoia, and aggression over several months, which was reported by both staff and other residents, but these reports did not result in timely or adequate changes to the care plan or interventions. The resident's behavioral symptoms included verbal and physical aggression, accusations against other residents, and episodes of paranoia. Staff and residents reported that the resident would yell, threaten, and accuse others of stealing, and that these behaviors escalated to the point where the resident physically assaulted another resident, causing injury. Despite these incidents, documentation shows that the care plan remained largely unchanged, and recommendations from psychiatric and psychological providers were not incorporated into the resident's plan of care. There was also a lack of documentation regarding changes in care or notification of psychiatric or psychological services following episodes of increased aggression or hallucinations. Interviews with staff revealed that while some staff attempted to manage the resident's behaviors by separating him from others or redirecting him, there was inconsistency in reporting and addressing the behaviors. Some staff did not report incidents because they felt they could handle them, while others reported behaviors but were unsure if any action was taken. The DON and Administrator were not aware of the extent of the resident's behaviors until a serious incident occurred, resulting in police intervention and the resident's removal from the facility. The lack of timely and effective behavioral interventions and care plan updates contributed to an unsafe environment for both the resident and others.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident willfully hit them in the face, resulting in swelling and pain. The incident occurred when one resident, who had a history of major depressive disorder, substance abuse, and anxiety, believed that the other resident was going through their belongings. This resident had previously exhibited violent and paranoid behavior, including threatening other residents and accusing them of stealing. Despite these behaviors, the facility did not provide a copy of their Abuse/Neglect policy when requested, and there was no indication that staff had taken adequate measures to prevent the incident. Interviews with various residents and staff revealed that the aggressive resident had been displaying paranoid and volatile behavior, which was reported to the nursing staff. On the night of the incident, the aggressive resident was seen pacing and sweating, and had verbal altercations with the victim. Despite attempts by staff to separate the residents and calm the aggressive resident, the situation escalated, leading to the physical assault. The police were called, and the aggressive resident was arrested and taken to the hospital after assaulting the police and paramedics. The Director of Nursing and the Administrator were not aware of any prior issues between the two residents, although the aggressive resident had been sent to the hospital the previous month for similar behaviors. The facility's failure to monitor the aggressive resident closely and to implement one-on-one monitoring, as expected by the Administrator, contributed to the incident. The lack of a documented Abuse/Neglect policy and the absence of proactive measures to address the aggressive resident's behavior highlight deficiencies in the facility's handling of resident safety and abuse prevention.
Failure to Manage Resident's Aggressive Behavior
Penalty
Summary
The facility failed to effectively manage the behaviors of a resident, leading to a physical assault on another resident. The resident in question had a history of major depressive disorder, substance abuse, generalized anxiety disorder, and schizophrenia. Despite these diagnoses, the resident's care plan was not updated to address their mood, mental status, or anger management. The resident exhibited aggressive and paranoid behaviors, including accusing other residents of theft and physically assaulting another resident, causing injury. The facility's behavior management program was not adequately implemented for this resident. There were no updates or new interventions in the care plan to address the resident's aggression, hallucinations, or safety concerns. The staff failed to document changes in care needed following episodes of increased aggression and did not notify psychology or psychiatry of the resident's worsening behaviors. Despite multiple incidents of aggression and paranoia, the resident's care plan remained unchanged, and there was no evidence of 1:1 monitoring or behavior modification strategies being employed. Interviews with staff and other residents revealed that the resident's behaviors had been escalating over several months, yet these concerns were not effectively communicated to the Director of Nursing or the Administrator. Staff reported the resident's behaviors to nurses, but there was no indication that these reports led to any changes in the resident's care plan. The lack of appropriate interventions and monitoring ultimately resulted in a violent incident, highlighting the facility's failure to provide necessary behavioral health care and services to ensure the safety and well-being of all residents.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) met the necessary qualifications for a Certified Dietary Manager (CDM). The DM, hired on September 7, 2023, did not possess a national certification for food service management and safety, an associate's degree in food service management or hospitality, nor had two or more years of experience in the position of director of food and nutrition services in a nursing facility setting with completed coursework in food safety and management. During interviews, the DM confirmed that the facility had not assisted in obtaining the required qualifications, and the Administrator acknowledged awareness of the DM's lack of qualifications but had not taken further action beyond discussing the need for certification. This deficiency potentially affected all 89 residents in the facility.
Menu Deviations in Dietary Services
Penalty
Summary
The facility failed to adhere to the planned menu on three separate occasions, potentially affecting all 89 residents. On 11/17/24, during lunch service, the facility did not serve the Homemade Peach Crisp as listed on the menu. Instead, residents received orange ice cream because the dietary staff ran out of time to prepare the peach crisp. On 11/19/24, during lunch, residents were served a rye swirl bread sandwich with fries instead of the planned Sweet and Sour Chicken with Steamed Rice and Oriental Vegetables. The chicken intended for the Sweet and Sour Chicken was used earlier as a substitute for another meal due to a defrosting issue with pulled pork. During the dinner service on 11/19/24, the facility deviated from the menu again. Residents were supposed to receive a Classic Patty Melt with Crispy French Fries, but instead, they were offered a choice of ham with cheese, turkey with cheese, or grilled cheese sandwiches, and no fries were served. The fries were used during the lunch meal, leading to their absence at dinner. These deviations from the menu were confirmed through observations and interviews with the dietary staff, who cited time constraints and ingredient availability as reasons for the discrepancies.
Absence of Certified Infection Preventionist
Penalty
Summary
The facility failed to employ a certified Infection Preventionist (IP) as required, impacting their infection prevention and control program. The facility's policy mandates that the IP must complete training programs through CDC TRAIN and maintain documentation of these certifications in their personnel record. However, interviews revealed that the facility had not had an IP since August, and the Administrator admitted to starting but not completing the necessary course. Both an LPN and the Director of Nursing confirmed the absence of an IP at the facility, which had a census of 89 residents.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to implement effective pest control measures, resulting in a significant presence of roaches in various areas, including the kitchen, dining room, and resident rooms. Observations revealed dead and live roaches in multiple locations such as under the microwave table, behind the reach-in refrigerator, inside electrical outlets, and under the dishwasher where grime and food debris had accumulated. The Dietary Manager acknowledged the presence of roaches and the difficulty in cleaning certain areas due to tight spaces. The Maintenance Director confirmed that exterminators visited the facility twice a month, but the pest issue persisted. Further observations showed roaches crawling on walls, tables, and ceilings in the kitchen and dining areas. Roaches were also found in food storage areas, such as the spice storage table and tea bag box, and even inside a delivery tray cart. The Dietary Manager expressed frustration with the ongoing pest problem, noting that the roaches began appearing in September 2024. Interviews with staff indicated that cleaning under the dishwasher had not been done for about four months, contributing to the pest issue. Roaches were also observed in resident rooms, with one cognitively intact resident confirming previous sightings of roaches in their room. The facility's extermination service records showed sporadic visits over the past six months, with the Maintenance Director planning to increase the frequency of visits. The Health Inspector from the municipal Health Department corroborated the presence of roaches and grime during a recent inspection, highlighting the widespread nature of the infestation. The Director of Operations became aware of the problem shortly before the survey and initiated more frequent extermination visits.
Failure to Provide Required CNA In-Service Training
Penalty
Summary
The facility failed to provide the required annual 12 hours of in-service training for Certified Nursing Assistants (CNAs) and did not maintain records indicating the subject of, and attendance at, all in-service sessions. Interviews with the Administrator and various staff members revealed a lack of documentation and uncertainty about the number and topics of in-services held over the past year. The facility's policy mandates that CNAs complete a minimum of 12 hours of continuing education annually, but the Administrator was unable to locate any records of such training. Additionally, CNAs reported that it had been a long time since they received any in-service education, particularly on handling resident behavioral issues. The Director of Nursing (DON) acknowledged that in-services should be held monthly and that CNAs should receive at least 12 hours of training annually. However, the DON admitted to conducting only eight to nine in-services throughout the year, none of which were documented. The DON also mentioned that individual education was provided when needed but was not documented. The facility does not offer online computer education, and there was no set schedule for observing staff competencies. This lack of structured and documented training and education led to the deficiency identified in the report.
Insufficient Bond Amount for Resident Personal Funds
Penalty
Summary
The facility failed to ensure that the bond amount for resident personal funds was sufficient to cover the average monthly balance for the 12-month period from November 2023 through October 2024. The average monthly balance of reconciled bank statements was $123,720.44, which, when rounded up to the nearest thousand and multiplied by 1.5 as per the Resident Fund Bond Worksheet instructions, required a bond amount of $186,000.00. However, the facility's bond was only $150,000.00, which was insufficient. This deficiency potentially affected 56 residents who allowed the facility to manage their trust accounts. During an interview, the bookkeeper acknowledged the need to increase the bond amount and admitted to not having a process in place to regularly check the average monthly balance.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by several observations of unclean conditions. In the dining room, there was a buildup of food crumbs on the handrails, and roaches were observed crawling near the end of the handrail. The Dietary Manager acknowledged responsibility for cleaning the handrails and was aware of the presence of roaches. Additionally, a Dietary Aide mentioned that cleaning of the handrails would be initiated on a weekly basis after noticing the accumulation of crumbs. Further observations revealed a significant buildup of dust in various areas of the facility, including restroom ceiling vents and personal fans in multiple resident rooms. The Maintenance Director admitted to not having noticed the dust on the fan blades and had not yet cleaned the ceiling vents. Despite having cleaned a fan the previous day, dust was still present. These conditions potentially affected at least 55 residents residing in the affected rooms or using the areas, with the facility census being 89 residents.
Medication Mismanagement at Bedside
Penalty
Summary
The facility failed to ensure medications were not left at the bedside for three residents, which was observed during a survey. Resident #23, who was diagnosed with depression, psychosis, and vascular dementia, was found with six pills in a medication cup on the bedside tray table while asleep. The resident's care plan indicated the need for supervision and administration of medications by staff, and there was no physician's order for self-administration of medications. Resident #27, diagnosed with depression and psoriasis, was observed with Nystatin powder at the bedside, despite not having a physician's order to self-administer medications. The resident claimed that the physician allowed them to keep the medication at the bedside for self-application. However, the care plan did not reflect the ability to self-administer medications, and there was no official order supporting this practice. Resident #50, with a history of traumatic brain injury and substance abuse, was found with two pills in a medication cup on the nightstand while not present in the facility. The resident reported that staff would leave medications for them to take upon return. Interviews with staff, including a CMT and an LPN, confirmed that medications were left at the bedside, contrary to the facility's policy and without physician orders for self-administration. The Administrator and DON acknowledged the issue and stated that staff had been educated on proper medication administration procedures.
Deficiency in CPR Certification Tracking and Staffing
Penalty
Summary
The facility failed to ensure that all staff members had current CPR certifications on file and that certified staff were available on all shifts. This deficiency had the potential to affect 80 residents who were designated as full code status, meaning they would require CPR in an emergency. The facility's policy required at least one CPR-certified staff member per shift, but a review of staffing schedules revealed that 16 out of 41 sampled shifts lacked verified CPR-certified staff. Interviews with staff, including the Administrator, revealed that there was no effective system in place to track CPR certifications or ensure compliance with the facility's policy. The Administrator acknowledged the lack of a system to monitor CPR certifications and admitted difficulty in obtaining copies of CPR cards from staff. Interviews with various staff members, including CNAs and LPNs, indicated uncertainty about their CPR certification status, with some not being current or unsure if they had been offered training. The Director of Nursing and the Administrator both recognized the need for CPR-certified staff on each shift but confirmed the absence of a reliable tracking system for CPR certifications and renewals.
Failure to Maintain Nutritional Status and Document Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for a resident, resulting in an unplanned weight loss. The deficiency was identified through observation, interview, and record review, revealing that the facility did not follow physician instructions for weighing residents. Specifically, a resident experienced a significant weight loss of 5.77% in 30 days and 7.05% from June to October 2024, without proper documentation or notification to the physician or registered dietician (RD). The facility's policy required the Director of Nursing (DON) or Assistant DON to establish a weight schedule, and nursing staff were responsible for obtaining and documenting weights. However, there were multiple instances where weights were not recorded as ordered, and health shakes prescribed to address weight loss were inconsistently provided. Interviews with Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) revealed a lack of awareness and documentation regarding the resident's weight loss and the administration of health shakes. The resident, who was severely cognitively impaired and required substantial assistance with eating, was on a Low Concentrated Sweets diet and had diabetes. Despite orders for weekly weights and health shakes, the facility failed to ensure these interventions were consistently implemented and documented. The RD, who had recently joined the facility, was not fully aware of the resident's weight history or dietary needs, further contributing to the deficiency.
Inadequate Cleaning and Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure that respiratory equipment such as oxygen tubing, CPAP machines, and nebulizers were cleaned and stored in a sanitary condition for three residents. Resident #22, who was admitted with COPD, had a nebulizer pipe that was not stored in a bag or dated, and it was observed hanging off the nightstand and touching the floor. The resident reported that staff did not change or clean the pipe regularly, and the mouthpiece was noted to be yellowed. Resident #34, who used a CPAP machine for sleep apnea, had a CPAP mask that was not stored in a bag and was mixed with personal belongings in a drawer. The resident was unsure of when the mask was last cleaned, and the mask was observed to be slightly yellow tinged. The care plan did not mention cleaning or storage instructions for the CPAP equipment. Resident #62, who had COPD and chronic respiratory failure, had oxygen tubing and a nebulizer mask that were not stored in bags and were found on the floor. The resident indicated that staff changed the tubing infrequently and did not use detergent to clean the nebulizer mask. Interviews with staff revealed inconsistencies in the cleaning and storage practices for respiratory equipment, despite education provided by the administration.
Failure to Post Accessible and Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted correctly and accessibly at the beginning of each shift. Observations over several days revealed that staffing sheets were either not posted or not readily accessible to residents and visitors. On multiple occasions, the staffing sheets were placed in locations that were not easily visible or reachable, such as on top of nurse's station counters or hanging on walls above counters, making them inaccessible to residents in wheelchairs and visitors. Additionally, the staffing sheets did not include the total hours worked per nursing discipline, which is a required detail. Interviews with staff, including a Certified Medication Technician and a Certified Nursing Assistant, indicated a lack of awareness about the location of the staffing sheets and confirmed that the sheets did not list the total hours worked. The Director of Nursing acknowledged that while the sheets were posted daily, they did not include the total hours worked for each nursing discipline. This oversight in posting and detailing staffing information could potentially affect all visitors and residents in the facility, as it does not comply with the requirement to provide transparent and accessible staffing information.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to maintain proper storage and handling of medications in the medication rooms on both the first and second floors. Observations revealed that the medication refrigerator on the first floor lacked a temperature log, and the thermometer inside showed a temperature of 46 degrees Fahrenheit. Insulin boxes stored in the refrigerator were found wet, with one box tearing apart when moved, and water running off another box. Additionally, an opened vial of Tuberculosis skin test had expired several months prior. The only sink in the medication room was observed to be dirty and rusty. Interviews with staff indicated a lack of clarity regarding responsibility for checking refrigerator temperatures and ensuring the removal of expired medications. On the second floor, similar issues were noted, with no temperature log available for the medication refrigerator, which showed a temperature of 38 degrees Fahrenheit. An expired vial of Tuberculosis skin test was also found. Staff interviews revealed that the night nurse was supposed to check and document refrigerator temperatures and remove expired medications, but this was not being done. Housekeeping was expected to clean the medication rooms daily, including the sink, but this was not occurring. The Director of Nursing and Administrator were unaware of the issues with the wet insulin boxes and the lack of temperature logs.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards in the kitchen, as observed during a survey. Dietary Aide A was seen working with hair not fully restrained, which is a violation of food safety protocols. Additionally, a bottle of jelly was not refrigerated as required by its label, indicating a lapse in following storage instructions. The kitchen also had several areas with significant cleanliness issues, including grime buildup under the dishwasher, food grime on bread toaster knobs, and dust accumulation on fan vent covers in the walk-in refrigerator. These conditions were observed over a period of time, suggesting a lack of regular cleaning and maintenance. Interviews with dietary staff revealed a lack of adherence to expected practices. Dietary staff acknowledged the oversight in refrigerating items and the infrequent cleaning of kitchen equipment and areas. The Dietary Manager admitted that the fan vent covers had not been cleaned since May 2024, and the area under the dishwasher had not been cleaned since July 2024. The fan closest to the steam table was also found to have a heavy buildup of dust, which had not been addressed for some time. These deficiencies potentially affected all residents consuming food from the kitchen, given the facility's census of 89 residents.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility failed to adhere to its tuberculosis (TB) screening policy for residents and employees. Five residents did not receive annual TB screenings as required, and there was no documentation of TB testing or screening for several new employees. The Director of Nursing (DON) admitted to being too busy to complete the necessary screenings, and the Administrator confirmed that if the screenings were not documented, they were not done. Additionally, the facility did not maintain a TB log as required by their policy. Infection control practices were not followed during blood glucose monitoring for five residents, as the glucometer was not sanitized between uses. The facility's policy required glucometers to be cleaned and disinfected if used for multiple residents, but observations showed this was not done. The DON acknowledged the expectation for staff to disinfect the glucometer and the area where it was placed, but there was no recent in-service training on the proper procedure. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDROs) or those requiring high-contact care. There was no policy for EBP, and staff were not educated on its requirements. Observations showed a lack of personal protective equipment (PPE) and signage for EBP, and the DON and Administrator were unaware of the EBP requirements. Additionally, insulin pens were not sanitized before use, contrary to the facility's policy, indicating a broader issue with infection control practices.
Deficiency in Vaccine Offering and Documentation
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal vaccines were offered, administered, or documented for several residents, leading to deficiencies in their immunization practices. Specifically, three residents were not offered the flu vaccine, and two residents were not offered the pneumococcal vaccine five years after their previous vaccination. The facility's policy required that all newly admitted residents be offered these vaccines, with documentation of acceptance or declination, but this was not consistently followed. Resident #23, who was severely cognitively impaired, had received a flu vaccine in 2021 but had no documentation of receiving or declining the flu vaccine for the 2023 or 2024 seasons. Additionally, there was no record of a pneumococcal vaccine being offered or administered five years after the last one in 2017. Resident #22's records also lacked documentation of receiving or declining the flu vaccine upon admission. Similarly, Resident #79, who had multiple health conditions, was not offered or documented as having received or declined the influenza and pneumococcal vaccines upon admission. Interviews with facility staff revealed inconsistencies in the process of obtaining vaccine consents and documentation. The Licensed Practical Nurses (LPNs) and the Director of Nursing (DON) indicated that the responsibility for offering and documenting vaccines was shared among staff, but there were lapses in execution. The administrator admitted to not having time to ensure vaccines were offered and documented, relying on other staff members to fulfill these duties. This lack of coordination and adherence to policy resulted in the failure to provide necessary immunizations to residents, as evidenced by the missing documentation and delayed vaccine clinics.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure the 2024-2025 COVID-19 vaccine was offered, administered, or documented for two residents out of five sampled for immunizations. Resident #23, who was severely cognitively impaired, had received initial COVID-19 immunizations and a booster in previous years, but there was no documentation of the 2024-2025 vaccine being offered or administered. Resident #79, with intact cognition, had a record indicating the COVID-19 vaccine was due, but there was no documentation of the vaccine being offered, administered, or declined upon admission. A form indicating the resident declined the vaccine was only provided after the surveyor's request. Interviews with facility staff revealed that the usual process involved a nurse manager obtaining vaccine consents, and any nurse could administer the vaccines once consents were obtained. However, the Director of Nursing and the Administrator admitted that they had not had time to ensure the vaccines were offered and documented this year, delegating the task to other nursing staff. Despite having a pharmacy visit the facility to administer vaccines on two occasions, the facility did not have a COVID-19 vaccine policy available for review.
Call System Audibility Issue on 2nd Floor
Penalty
Summary
The facility failed to ensure that the call system was audible at the nurse's station on the 2nd floor, potentially affecting 46 residents. Observations on November 18, 2024, revealed that when call lights were activated in various resident rooms and bathing areas, there was no audibility at the nurse's station. This issue persisted throughout multiple checks between 10:04 A.M. and 11:27 A.M., indicating a consistent problem with the call system's audibility. Interviews with staff members, including an LPN, a CNA, and the Maintenance Director, confirmed the issue. The LPN mentioned that they keep up with residents despite not hearing the call lights, while the CNA noted that the call lights only blinked on the panel without sound. The Maintenance Director identified the problem as related to the panel, and the Corporate Maintenance Person explained that the volume was turned down too low due to an override caused by the North Stairwell door activation. The panel required resetting after the stairwell door was opened, which contributed to the deficiency.
Facility Safety and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents and staff. Observations revealed a significant buildup of dust under the vending machines in the second-floor dining room. The Maintenance Director acknowledged the difficulty in cleaning under the machines due to their weight and indicated that the vending machine company would need to be contacted to move them for cleaning. Additionally, the threshold of the door between the carport and the basement entrance was found to be loose, posing a tripping hazard. This issue had been present for a few weeks, as confirmed by the Maintenance Director. These deficiencies potentially affected at least 25 residents who used the carport as a smoking area and an unknown number of staff who accessed the facility through that door.
Failure to Ensure Dignified Feeding Assistance
Penalty
Summary
The facility failed to ensure that Resident #56, who was legally blind and severely cognitively impaired, was treated with dignity and respect during assisted feeding. The resident required substantial assistance with eating, as noted in their care plan and Minimum Data Set (MDS). However, during an observation, a Certified Nursing Assistant (CNA) did not provide appropriate assistance, allowing the resident to spill milk on themselves and the floor without offering a napkin or cleaning assistance. The CNA stood over the resident, rather than sitting beside them, and did not communicate effectively, simply saying 'eat' while placing food in front of the resident's mouth. Interviews with staff revealed a lack of training and monitoring regarding feeding assistance. CNA D admitted to not receiving specific training from the facility on how to assist the resident with dining. Other CNAs and Licensed Practical Nurses (LPNs) also indicated that they had not received recent training on feeding assistance since their initial CNA classes. The Director of Nursing (DON) acknowledged that in-services were not held regularly, and individual education was not documented, leading to inconsistent practices among staff. The facility's policies on feeding assistance and resident rights emphasized the importance of dignity and respect, yet these were not adhered to in practice. The DON confirmed that there was no set process for feeding residents, and staff were expected to rely on their initial training. This lack of structured training and monitoring contributed to the deficiency in providing dignified and respectful care to Resident #56 during meals.
Failure to Conduct Background Checks and Maintain Employee Records
Penalty
Summary
The facility failed to conduct a Criminal Background Check (CBC) and Employee Disqualification List (EDL) check for three sampled employees, specifically Employees D, J, and K. Additionally, the facility did not maintain records of the Social Security number, date of birth, date of employment, experience and education, references, and the result of background checks for Employees J and K, as required by section 660.317 of the Revised MO Statutes. The facility's policy mandates that all prospective employees must have a CBC and EDL check prior to employment, and these checks should be completed no longer than five days before the first day of employment. However, Employee D was hired using a CBC and EDL check conducted by a different facility within the corporate network, and no recent checks were performed when Employee D was hired by the current facility. Furthermore, the files for Employees J and K were not available, and there was no evidence that CBC and EDL checks had been completed for them. During an interview, the Administrator admitted that the files for Employees J and K could not be found. This lack of documentation and failure to conduct the necessary background checks represent a significant deficiency in the facility's hiring and record-keeping processes, potentially compromising the safety and well-being of the residents.
Inadequate Discharge Planning and Coordination
Penalty
Summary
The facility failed to plan, coordinate, and provide a safe and appropriate discharge for a resident, resulting in a deficiency. The resident, who had been admitted with diagnoses including Major Depressive Disorder, psychoactive substance abuse, and Generalized Anxiety Disorder, was given an immediate discharge notice due to extreme violent behavior, drug use, and being a danger to themselves and others. The discharge notice incorrectly stated that the resident would be transferred to another facility, Facility B, but the resident was instead transported to a hospital by Emergency Medical Services. Facility B was unaware of any arrangements for the resident's transfer. The facility's Discharge and Transfer Resident policy required that all discharges be ordered by the attending physician and that involuntary discharges be reviewed by the Safety Committee. However, there was no physician order for the discharge of the resident, and the discharge notice was issued without proper coordination. The resident was handcuffed by police, sedated by paramedics, and taken to a local hospital, indicating a lack of proper planning and communication regarding the discharge process. Interviews with facility staff revealed that the Administrator was responsible for initiating the discharge and claimed to have made arrangements with Facility B, but this was not corroborated by Facility B's staff. Additionally, the discharge notice provided to the resident contained outdated and incorrect information, including the contact details for the Ombudsman and the appeals unit. The Ombudsman filed an appeal against the discharge, highlighting the deficiencies in the discharge process and documentation.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives of transfers to a hospital, including the reason for the transfer in writing, and did not provide the Ombudsman with a copy of the notification for two residents. This deficiency was identified during a review of the facility's practices and policies, which revealed that the facility did not adhere to its own Bed-Hold Policy and Readmission procedures. Specifically, the policy required written notice to be provided to the resident and a family member or legal representative at the time of transfer, and for the discharge to be logged and faxed monthly to the Ombudsman office. For Resident #14, the facility's records showed that the resident was sent to the hospital on two occasions without documentation of notification to the resident, family, or legal representative. Additionally, there was no discharge notice sent to the Ombudsman for these transfers. Similarly, Resident #30 was transferred to the hospital twice without proper notification to the resident, family, or legal representative, and no discharge notice was sent to the Ombudsman. Interviews with facility staff, including an LPN, the Social Services Designee (SSD), and the Director of Nursing (DON), confirmed that the facility did not send a list of residents discharged to the hospital to the Ombudsman monthly, as required. The staff also acknowledged that they did not send written notices of discharge to the residents or their representatives, and the facility did not notify the Ombudsman of residents returning from the hospital.
Inaccurate MDS Assessment for Bed Rail Use
Penalty
Summary
The facility failed to accurately complete the Resident Assessment Instrument/Minimum Data Set (RAI/MDS) for a resident, leading to an inaccurate care plan. Specifically, the facility did not properly assess and record the use of bed rails for a resident who was severely cognitively impaired and legally blind. The resident's MDS indicated that bed rails were not in use, yet observations showed that the resident's bed had rails on both sides. Interviews with staff revealed inconsistencies in their understanding of whether the resident had bed rails or positioning bars, and there was no documented assessment for bed rails in the resident's medical chart. The Director of Nursing (DON) and other staff members provided conflicting information regarding the presence and purpose of the bed rails, with some referring to them as positioning bars. The facility's policy required that bed rail assessments be conducted and documented, but this was not done for the resident in question. The lack of a proper assessment and documentation led to a discrepancy between the resident's actual needs and the care plan, as the use of bed rails or positioning bars was not accurately reflected in the MDS or the resident's medical records.
Deficiencies in Care Plan Review and Documentation
Penalty
Summary
The facility failed to review and revise a resident's person-centered care plan, specifically regarding the use of bed rails for a resident who was legally blind and severely cognitively impaired. The resident's care plan did not indicate the use of bed rails, although observations showed that the resident's bed had rails on both sides. Interviews with various staff members, including CNAs and LPNs, revealed inconsistencies in their awareness and understanding of the resident's use of bed rails or positioning bars. The Director of Nursing (DON) confirmed that the resident had a positioning bar, which should have been documented in the care plan and the Minimum Data Set (MDS). Another deficiency was identified when the facility failed to ensure the accuracy of a resident's care plan by dating it eight days after the resident had been discharged. The resident was discharged with no return anticipated, yet the care plan was initiated post-discharge, with no documentation showing a care plan was developed and utilized prior to the resident's discharge. The DON and the Administrator acknowledged that the care plan should not have been completed after the resident's discharge. The facility's policy for care planning, dated 2022, outlined the need for effective communication of a resident's comprehensive plan of care, development of new care plans for new conditions, and quarterly reviews. The policy also specified the roles of various staff members in the care planning process. However, the facility failed to adhere to these guidelines, resulting in deficiencies related to the care planning for the two residents.
Non-Compliance with Smoking Policies in LTC Facility
Penalty
Summary
The facility failed to ensure that both staff and residents adhered to the designated smoking areas, leading to multiple instances of smoking in prohibited areas. Observations revealed that kitchen staff members were smoking outside the kitchen door, despite the presence of 'No Smoking' signs and combustible materials like dried leaves nearby. Additionally, a half-smoked cigarette was found in a women's restroom, which also had a 'No Smoking' sign, indicating non-compliance with the facility's smoking policy. Two residents, identified as Resident #50 and Resident #55, were found to be smoking in their rooms, contrary to the facility's smoking policy. Resident #50, who had a history of traumatic brain injury, psychoactive substance abuse, and alcohol abuse, was observed with a lighter and cigarettes in their room. The resident's room frequently smelled of marijuana, and drug paraphernalia was found during a deep clean. Despite being placed on 15-minute checks, there were lapses in monitoring, and the resident continued to smoke in their room. Resident #55, who had a history of amnesia and polyneuropathy, admitted to smoking in their room and was observed with smoking materials in their possession. Interviews with staff revealed a lack of consistent enforcement of the smoking policy and inadequate monitoring of residents known to smoke in prohibited areas. The facility's policies required residents found smoking in non-designated areas to be placed on 15-minute checks, but these checks were not consistently documented or performed. Staff members were also observed smoking in non-designated areas, indicating a broader issue of non-compliance with the facility's smoking policies. The facility's failure to enforce its smoking policies and adequately supervise residents and staff contributed to the deficiencies observed.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the dialysis center for a resident requiring dialysis services. The facility's policy required a communication record to be sent with the resident each day they attended dialysis, and the form was to be completed by the nursing home. However, for one resident, only six forms were present when there should have been 20 for the period from October through mid-November. Additionally, three of these forms were not dated, indicating a lack of consistent documentation and communication. Interviews with staff revealed that the nurses were responsible for sending the dialysis forms with the resident and retrieving them upon return. If the form was not returned, the nurse was expected to contact the dialysis center to obtain the necessary information. The Director of Nursing confirmed that the forms were crucial for documenting the resident's weight before and after dialysis, among other details. The failure to consistently receive and document this information resulted in a lack of knowledge about the resident's dialysis treatment details, such as weight changes, which are critical for ongoing care management.
Failure to Follow Bed Rail Policy for Resident Safety
Penalty
Summary
The facility failed to ensure resident safety by not adhering to their Restraint Policy regarding the use of bed rails. A resident, who was legally blind and severely cognitively impaired, was observed with bed rails attached to their bed, despite the facility's policy requiring a thorough assessment and documentation process before bed rails are used. The resident's care plan and medical records did not reflect the use of bed rails, and there was no documented assessment or physician order for their use. Interviews with staff revealed inconsistencies in their understanding of whether the resident had bed rails or a positioning bar, and there was no clear communication with the resident's guardian regarding the use of such equipment. The facility's policy mandates that residents with compromised mobility be assessed for bed rail use upon admission and reassessed monthly. However, the resident's records showed no such assessments were completed. Staff interviews indicated a lack of awareness and understanding of the resident's equipment, with some staff believing the resident had a positioning bar rather than bed rails. The Director of Nursing (DON) also mentioned that a physician order and care plan indication were necessary for a positioning bar, which were absent in this case. The resident's guardian was not informed or consulted about the use of bed rails or a positioning bar, highlighting a communication gap between the facility and the resident's representative.
Deficiency in Food Labeling and Storage
Penalty
Summary
The facility failed to ensure that foods stored in the resident use refrigerator were labeled with a resident's name and the date the food was brought in, as required by their policy. This deficiency was identified through observation, interview, and record review. Specifically, the refrigerator at the 2nd floor nurse's station contained a package of ham and a container of milk that were expired, as well as two packages of food that were not labeled with a resident's name or the date they were brought in. During an interview, an LPN stated that they had not worked on their shift for several days and were unsure of whose responsibility it was to check and discard items from the refrigerator. This practice potentially affected at least three residents whose food was stored in the refrigerator, with the facility census being 89 residents.
Failure to Maintain Closed Dumpster Lids
Penalty
Summary
The facility failed to maintain the outdoor dumpster with the lids closed, as observed on multiple occasions. On 11/17/24, the dumpster lid was observed open at 9:08 A.M., 9:58 A.M., and 10:15 A.M. Similarly, on 11/18/24, the lid remained open during observations at 9:49 A.M., 1:27 P.M., 2:06 P.M., and 2:47 P.M. Additional observations on the same day at 11:20 A.M. and 12:33 P.M. confirmed the lid was still open. Interviews with the dietary staff, including a dietary staff member and the Dietary Manager, revealed that they expected facility staff to close the lids after disposing of trash, indicating a failure to adhere to expected procedures.
Inaccurate Care Plan Completion Post-Discharge
Penalty
Summary
The facility failed to ensure the accuracy of a resident's care plan by dating it eight days after the resident had been discharged. The resident was admitted to the facility and later discharged to the hospital with an anticipated return date. However, the resident did not return as expected and instead informed the facility that they would be staying with a family member. Despite this, the care plan was initiated after the resident's discharge, with all focus areas, goals, and interventions dated after the resident had left the facility. The Director of Nursing (DON) and the Administrator acknowledged that care plans should be reviewed every three months and that the resident's care plan should not have been completed post-discharge. The facility's policy required the comprehensive care plan to be completed within 21 days of admission, and the care plan schedule was to follow the Resident Assessment Instrument (RAI) requirements. The failure to adhere to these standards resulted in the care plan being inaccurately dated after the resident's discharge.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, who was known to have a history of alcohol and psychoactive substance abuse. On two separate occasions, this resident, who smelled strongly of alcohol, physically assaulted two other residents without provocation. The first incident involved the resident entering another resident's room and hitting them in the mouth, causing a cut on the lower lip. The second incident involved the resident becoming agitated and striking another resident in the cheeks, resulting in cuts that required stitches. The facility's policy on abuse and neglect, revised in 2022, clearly states that residents have the right to be free from abuse and that the facility is responsible for preventing abuse by anyone, including other residents. Despite this policy, the facility did not take adequate measures to prevent the resident with a known history of substance abuse from harming others. Interviews with staff revealed that there was a lack of intervention when the resident became agitated, and the incidents were not properly reported to the medical staff responsible for the resident's care. The Director of Nursing and the Administrator expressed expectations that staff should have intervened to prevent the violent behavior and protect vulnerable residents. However, the Administrator questioned the conclusion of abuse due to the lack of witnesses and the fact that both residents involved in the incidents smelled of alcohol. This indicates a failure in the facility's response to the incidents and a lack of adherence to their own policies regarding resident safety and abuse prevention.
Failure to Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to report two incidents of resident-to-resident abuse involving Resident #2, Resident #6, and Resident #1. On 7/3/24, Resident #2 hit Resident #6 in the mouth, causing a small cut on the lower lip. Despite the incident being documented by LPN C and communicated to the oncoming nurse, it was not reported to the Director of Nursing (DON) or the Administrator. Similarly, on 7/22/24, Resident #2 hit Resident #1, resulting in lacerations on both cheeks. This incident was reported to the DON and Administrator by LPN B, but no report was made to the state agency. The facility's policy on abuse and neglect, revised in 2022, mandates immediate reporting of abuse incidents to the charge nurse, who should then inform the DON and/or Administrator. The policy also requires that any abuse resulting in serious bodily injury be reported to all required entities within two hours. However, the staff failed to adhere to these procedures, as evidenced by the lack of notification to the DON and Administrator regarding the incident on 7/3/24 and the absence of a report to the state agency for both incidents. Interviews with staff and residents revealed a breakdown in communication and reporting. LPN A did not recall notifying anyone about the 7/3/24 incident, assuming it was the responsibility of another nurse. The DON and Administrator were unaware of the 7/3/24 incident until much later, and the Administrator questioned whether the 7/22/24 incident constituted abuse, citing the lack of witnesses and the presence of alcohol. This confusion and failure to report highlight significant deficiencies in the facility's handling of abuse allegations.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of resident-to-resident abuse involving two residents. On 7/3/24, one resident entered another resident's room and hit them in the mouth, resulting in a cut lip. Despite the incident being reported to the police, who took the aggressor to the hospital due to lack of jail space, the facility did not conduct an investigation as required by their policy. The facility's policy mandates immediate investigation of all abuse allegations by administrative staff, but this was not followed. Interviews with staff revealed a breakdown in communication and responsibility. LPN A did not notify the necessary parties, assuming it was the responsibility of another nurse. LPN C believed they had documented the incident and informed the DON and Administrator, but this was not confirmed. The DON and Administrator were unaware of the incident and thus did not initiate an investigation. The lack of notification and documentation led to a failure in addressing the abuse allegation appropriately.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 792 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Summit, The | 0.6 mi | ★★★★★ | 1 | 0 |
| Bishop Spencer Place, Inc, The | 1.1 mi | ★★★★★ | 18 | 0 |
| Parkway Health Care Center | 1.9 mi | ★★★★★ | 2 | 1 |
| Ignite Medical Resort Rainbow Boulevard, Llc | 2.5 mi | — | 0 | 0 |
| Myers Nursing & Convalescent Center | 2.5 mi | ★★★★★ | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.