Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Clarkson Community Care Center Inc during CMS and state inspections, most recent first.
The facility failed to provide a full-time DON, with the designated DON working primarily as Charge Nurse and only about 4 hours per week in the DON role. The DON was the only full-time RN in the building and reported that the schedule contributed to missed reporting of a resident fall with injury, an injury of unknown origin for another resident, and a missing discharge summary for a third resident.
Failure to obtain informed consent for psychotropic meds. The DON confirmed missing consent for multiple residents who had cognitive impairment, dementia, anxiety, depression, or TBI and were receiving antipsychotic, antianxiety, and antidepressant medications. In several cases, the consent on file did not match the current dose or did not include all active psychotropic orders, including Quetiapine/Seroquel, Lorazepam/Ativan, Buspirone, Sertraline, Trazodone, and Duloxetine.
The facility failed to keep care plans current for residents on EBP and residents with repeated falls. Two residents had EBP signs posted and staff were observed using gowns and gloves, but their care plans did not reflect EBP. Several residents with dementia, mobility impairment, and repeated falls had incidents documented in records and observations, yet their fall care plans were not revised to match the residents’ current status or interventions.
Failure to assess repeated falls and revise interventions. The DON confirmed that staff were to review each fall for causal factors and update the care plan, but records for several residents showed repeated falls without documented root-cause analysis or new fall-prevention measures. Residents with dementia, mobility impairment, and prior falls were found on the floor in multiple locations, with issues such as unlocked wheelchair brakes, nonworking alarms, and unsafe transfer attempts, yet the facility often did not document causal factors or revise interventions.
Failure to report suspected abuse/neglect and an injury of unknown origin: one resident had an unwitnessed fall with a head laceration and elbow pain requiring ER transfer and staples, but the event was not reported to the State Agency; another resident with a history of falls developed chest pain and was found to have a possibly new rib fracture, which was also not reported within the required timeframe.
Failure to investigate and timely report a fall with significant injury and an injury of unknown origin. One resident with impaired cognition, incontinence, and a history of falls had an unwitnessed fall in the room, sustained a head laceration requiring staples, and the facility had no documentation of an abuse/neglect investigation. Another resident with stroke, heart disease, arthritis, fractures, and high fall risk had X-ray findings of a possibly new rib fracture, but the DON confirmed the event was not investigated and was not reported to the State Agency on time.
Incomplete discharge summary for resident-initiated discharge: A resident admitted after a fall with a dislocated shoulder was discharged home with belongings and own meds, but the discharge summary-interdisciplinary form did not include the required recapitulation of the resident’s stay. The DON confirmed the discharge summary with the stay recap had not been completed.
Failure to Complete Significant Change MDS After Hospice Admission: A resident with cognitive impairment, TBI, and assistance needs for multiple ADLs was admitted to hospice, but the facility did not complete a significant change MDS when hospice began. No MDS assessments were completed for more than 2 months after the hospice admission, and the DON confirmed the omission.
A resident's MDS was coded inaccurately to show hypnotic medication use when the MAR and care plan did not support that coding. The resident had diagnoses including heart disease, HTN, and fractures, and the DON and an LPN confirmed the MDS Section N entry was incorrect because the medication was actually an antidepressant, not a hypnotic.
PASARR screening was not accurately completed for a resident who had anxiety, schizophrenia, and later documented schizoaffective disorder with bipolar disorder. The resident’s MDS, care plan, and MAR showed use of antipsychotic and antianxiety medications, including Latuda, but the PASARR did not document the antipsychotic use or mental health diagnosis. The DON confirmed the omission and stated it should have been included.
Incomplete Comprehensive Care Plan: A resident's care plan did not accurately reflect heart-related diagnoses or the use of several high-risk meds, including antidepressant, anticoagulant, diuretic, and anticonvulsant therapy. The plan focused on the resident's fall and rehab goals, but it did not include monitoring needs or black box medication warnings, and the DON confirmed the care plan was not comprehensive.
Failure to Complete AIMS Assessment for Resident Receiving Antipsychotic Medication. A resident receiving antipsychotic and antianxiety medications had diagnoses including anxiety, schizophrenia, schizoaffective disorder, and bipolar disorder. The facility’s psychotropic medication policy required AIMS monitoring on admission and at other specified intervals, but the resident’s AIMS form was left open with no documentation that the assessment was completed. The DON confirmed the AIMS assessment had not been completed and should have been done upon admission.
Hand hygiene was not completed at appropriate intervals during wound care for a resident with pressure injuries to the right knee and left great toe. An LPN/IP removed dressings from both wounds, changed gloves without sanitizing, cleaned both wounds using the same gloves, and then changed gloves again without hand hygiene before applying dressings. The DON confirmed wound care should be separated for each wound to prevent cross-contamination, and the LPN acknowledged using the same gloves and not performing hand hygiene between glove changes.
A resident with a history of pneumonitis and moderate cognitive impairment was given thin liquids instead of the prescribed honey thick liquids, leading to coughing and hospitalization. Staff interviews confirmed the oversight, with the DON acknowledging the failure to follow physician orders for thickened liquids.
The facility failed to follow proper infection control practices, including hand hygiene and gloving protocols, during resident care and COVID-19 testing. An LPN did not use gloves or clean a glucometer after a glucose test, and failed to change gloves between procedures involving a gastrostomy tube. The facility also lacked a water management program for Legionella and did not maintain proper infection control during COVID-19 testing, with used test kits and personal information left in plain sight.
The facility failed to maintain functioning bathroom ventilation systems in 11 out of 12 sampled rooms, as confirmed by observations and the Maintenance Director. Despite monthly safety checks, there was no documentation of regular operational checks, leading to lingering odors in the facility.
A facility failed to accurately code the MDS for a resident, omitting documented physical and verbal behaviors. The MDS, crucial for care planning, did not reflect behaviors noted in nursing progress notes and behavior flow sheets. The LPN and SSD confirmed the oversight, with the SSD not reviewing necessary documents or conducting interviews, leading to the deficiency.
A resident was discharged from LTC to assisted living without proper discharge planning or documentation. The facility did not obtain physician discharge orders, complete a discharge summary, or involve the resident and their representative in the planning process. The resident had a BIMS score indicating mild cognitive impairment, and the discharge was not discussed in care plan meetings.
The facility did not ensure that new employees received training on abuse, neglect, and exploitation during their initial orientation. Record reviews and interviews revealed that 7 out of 9 sampled employees, hired between January and April 2024, lacked documentation of completing the required abuse training. The Interim DON confirmed the absence of training, and the Administrator stated that the expectation was for new employees to complete the training before starting on the floor.
DON Not Scheduled Full Time in Leadership Role
Penalty
Summary
The facility failed to provide full-time hours for the designated Director of Nursing (DON), who was working as a Charge Nurse instead of serving in the DON role on a full-time basis. The DON job description stated the DON was responsible for overall management of the Nursing Department, coordination with other disciplines, staffing, and oversight of nursing services, and it also stated the DON should work during the day 4 to 5 days a week totaling 40 hours per week except when necessary to vary hours for supervision. The facility assessment staffing tool recommended a full-time DON along with additional nursing staff, including RNs, LPNs, medication aides, and CNAs. Review of the nursing schedules for August 2025 showed the DON worked multiple shifts as Charge Nurse, including day, evening, and overnight hours, and only designated approximately 4 hours per week for the DON role. During interview, the DON verified being the only full-time RN in the building and stated the current schedule resulted in the DON failing to report a fall with injury for one resident on 8/1/25 and an injury of unknown origin for another resident on 8/8/25 as potential abuse allegations, and failing to complete a Discharge Summary for a third resident after discharge home.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for Residents 12, 16, 17, and 29. The cited policy stated that residents were not to receive psychotropic drugs unless necessary for a specific diagnosed condition, that indications and targeted symptoms were to be documented, and that residents and/or their representatives were to be educated on the risks, benefits, and alternatives to psychotropic drug use. The survey found that the facility did not have evidence of informed consent for the psychotropic medications actually ordered and administered to these residents. Resident 12 had cognitive impairment and a traumatic brain injury, required assistance with bed mobility, transfers, toileting, bathing, and dressing, and received antipsychotic, antidepressant, and hypnotic medications. The resident’s care plan stated psychotropic medication was used for behavior management and that the resident/family/caregivers were to be educated about risks, benefits, side effects, and toxic symptoms. However, the informed consent form on file listed Seroquel 25 mg 1/2 tablet daily, while the active orders showed Seroquel 50 mg daily, Ativan 1 mg daily, Buspirone 5 mg twice daily, Lorazepam oral concentrate as needed, Sertraline 50 mg daily, and Trazodone 50 mg daily. The DON confirmed there was no evidence of informed consent for the current Seroquel dose or for the other psychotropic medications. Resident 16 had cognitive impairment, dementia, used a walker and wheelchair, required assistance with transfers, toileting, bathing, and dressing, and had bed, chair, and wander alarms in use. The resident’s care plan identified antipsychotic and antianxiety medication use for behavior management and stated the resident/family/caregiver were to be educated about risks, benefits, and side effects. The active medication orders included Lorazepam 0.5 mg daily and Quetiapine 50 mg twice daily, and the DON confirmed there was no evidence of informed consent for either medication. Resident 29 had dementia, anxiety, depression, and Parkinson’s disease, required assistance with bathing, dressing, hygiene, toileting, bed mobility, and transfers, and had mood, behavior, and hallucination concerns. Consent on file covered Seroquel 25 mg daily, but the active orders showed Quetiapine 50 mg daily and Duloxetine 60 mg daily, and the DON confirmed there was no evidence of consent for the current Quetiapine dose or for Duloxetine. Resident 17 had severe cognitive impairment, Alzheimer’s dementia, anxiety, and depression; consent was obtained for Sertraline 25 mg, but the active order was Sertraline 50 mg daily, and the DON confirmed there was no evidence of signed informed consent for the increased dose.
Care Plans Not Updated for EBP and Repeated Falls
Penalty
Summary
The facility failed to review and revise comprehensive care plans to reflect residents’ current status and interventions for Enhanced Barrier Precautions (EBP) and falls. The report states that the facility had policies for baseline care plans, comprehensive care plans, and care plan revision upon status change, but the care plans for Residents 5 and 6 did not document EBP even though staff were observed using gowns and gloves and EBP signs were posted on the residents’ doors. The Director of Nursing confirmed that both residents had EBP in place, yet the care plans were not updated to reflect that infection control intervention. Resident 12 was cognitively impaired, diagnosed with dementia, used a wheelchair and walker, and required assistance with transfers, toileting hygiene, dressing, and bathing. The resident had multiple falls and used bed, chair, and wander alarms daily. The record showed falls on 5/25/25, 6/8/25, 6/8/25, and 6/22/25, including being found on hands and knees in the lobby, sitting on the floor in another resident’s room, kneeling out of the wheelchair to pick up food, and falling near the nurses’ station after standing from a wheelchair. The care plan listed prior falls and interventions such as alarms, prompt response, and safety measures, but there was no evidence of new interventions being added after 5/13/25 despite repeated falls. Resident 16 was cognitively impaired, diagnosed with dementia, used a walker and wheelchair, and required assistance with transfers, toileting, bathing, and dressing. The resident had bed, chair, and wander alarms and sustained multiple falls with minor injury. The record documented falls on 5/21/25, 5/25/25, 5/30/25, 6/15/25, and 6/22/25, including being found on the floor beside the bed, on the floor with the forehead against the nightstand, and on a floor mat next to the bed with a bruised and bleeding area on the head. The care plan identified the resident as high risk for falls and included general interventions, but it was not updated after these repeated falls. Resident 7’s record showed multiple falls with no injury, minor injury, and major injury, while the care plan contained only one documented fall intervention in 2025. Incident reports documented falls on 3/27/25, 6/16/25, and 6/26/25, with the resident found on the floor in different positions and no immediate intervention noted. The DON confirmed that interventions were not changed or revised after those falls. Resident 24 had moderate cognitive impairment, bowel and bladder incontinence, and required moderate assistance with hygiene, dressing, transfers, toileting hygiene, and bed mobility. The resident had repeated falls, including being found on the floor next to the bed, outside the bathroom, seated on the floor after trying to transfer without locking wheelchair brakes, and later on the floor with a head laceration and elbow pain. The care plan listed several fall interventions, but the DON confirmed that the earlier falls were not identified on the care plan and that the bed and wheelchair alarms were no longer in use even though they remained listed in the plan.
Failure to assess repeated falls and revise interventions
Penalty
Summary
The facility failed to review falls for causal factors and failed to implement or revise interventions to prevent ongoing falls for multiple residents. The deficiency was based on interview and record review and involved Residents 12, 16, 7, and 24. The facility policy stated that the resident environment should remain free from accident hazards as possible, that each resident should receive adequate supervision and assistive devices to prevent accidents, and that the facility should use a systematic approach to identify, evaluate, analyze, implement, monitor, and modify interventions. The fall checklist also stated that each fall and intervention were to be added to the care plan and that the investigation should include a root cause analysis to prevent future falls. Resident 12 was cognitively impaired, had dementia, used a wheelchair and walker, and required assistance with transfers, toileting hygiene, dressing, and bathing. The resident had multiple falls with minor injuries and used bed, chair, and wander alarms. The record showed repeated falls in the hallway, lobby, linen closet, dining room, another resident’s room, and near the nurses’ station. Several events documented unsafe conditions or behaviors such as loose anti-rollbacks on the wheelchair, the wheelchair brakes not being locked, the resident turning off the alarm, and the resident slipping out of the wheelchair while trying to get a nightgown or reaching for food. The facility’s documentation did not show that causal factors were identified for several of the falls, and after one care plan update there was no evidence of additional interventions being implemented despite continued falls. Resident 16 had cognitive impairment, dementia, used a walker and wheelchair, and received assistance with transfers, bathing, dressing, and toileting. The resident was at high risk for falls and had bed, chair, and wander alarms in use. The record showed multiple falls in which the resident was found on the floor beside or in front of the bed, including one event where the resident reported sliding off the bed while trying to put on shoes and the pressure pad alarm was not working. Other falls were documented with no evidence that the facility identified a cause. The care plan stated staff were to review past falls to determine possible causes and alter causes if possible, but the record did not show updates to the care plan approaches after the repeated falls. Resident 7 was cognitively intact, independent with toileting, dressing, and hygiene, and had diagnoses including stroke, heart disease, arthritis, and fractures. The resident had a history of multiple falls, including falls with no injury, minor injury, and major injury. The care plan identified the resident as high risk for falls, but only one fall intervention was documented. Incident forms showed falls where the resident was found on the floor on hands and knees, on the floor by the bed on the left side, and sitting on the floor on the buttocks, with no immediate intervention documented for those events. Resident 24 had moderate cognitive impairment, bowel and bladder incontinence, required moderate assistance with personal hygiene, dressing, transfers, toileting hygiene, and bed mobility, and had a history of multiple falls without injury. The record showed several falls in which the resident was found on the floor next to the bed, outside the bathroom, seated on the floor after attempting to transfer from bed without locking wheelchair brakes, and on the floor after trying to get out of bed to use the bathroom. For several of these falls, the record did not show that causal factors were assessed or that new or revised interventions were developed, and one later fall had a new intervention of gripper socks at night.
Failure to Report Suspected Abuse/Neglect and Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or injuries of unknown origin to the State Agency for two residents. The facility policy required allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property to be reported immediately, and no later than 24 hours after discovery, or within 2 hours for serious bodily injury. Review of the facility’s reports showed no documentation that Resident 24’s unwitnessed fall with injury had been reported as a potential abuse or neglect allegation. Resident 24 had diagnoses including anemia, heart failure, stroke, and depression, was moderately cognitively impaired, incontinent, and required moderate assistance with several activities of daily living. After staff heard a loud noise and found the resident on the floor, the resident had a laceration to the back of the head, complained of right elbow pain, and was sent to the ER, where 9 staples were placed in the head wound and a sling was ordered for the arm. The facility also failed to report an injury of unknown origin for Resident 7 within the required timeframe. Resident 7 was cognitively intact, had diagnoses including stroke, heart disease, arthritis, and fractures, and was identified as high risk for falls with a history of multiple falls. The resident reported sharp left upper chest pain during therapy, was evaluated by the PCP, and X-rays later showed an old left 10th rib fracture and a left 8th rib fracture that could possibly be new, with the age unable to be determined. The DON confirmed the rib fracture was not reported to the State Agency within the required time frame.
Failure to Investigate and Report Significant Injury and Unknown-Origin Injury
Penalty
Summary
The facility failed to investigate and submit the results of investigations to the State Agency within the required time frame for two events: a fall with significant injury for one resident and an injury of unknown origin for another resident. The facility policy required all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property to be reported immediately, thoroughly investigated, and reported to the State Survey and Certification Agency within 5 working days of the event. One resident, admitted with diagnoses including anemia, heart failure, stroke, and depression, had moderately impaired cognition, bowel and bladder incontinence, required moderate assistance with several activities of daily living, and had a history of multiple falls. After an unwitnessed fall in the resident's room, the resident sustained a laceration to the back of the head and pain to the right elbow, was sent to the ER, and received 9 staples to the head. The facility's abuse/neglect reporting records contained no documentation that an investigation was completed for this fall. Another resident, who was cognitively intact and had diagnoses including stroke, heart disease, arthritis, and fractures, was identified as high risk for falls and had a history of falls and pain complaints. The resident later had X-ray results showing an 8th rib fracture that could possibly be new, but the facility did not investigate the rib fracture as an injury of unknown origin or submit a report to the State Agency within the required time frame.
Incomplete discharge summary for resident-initiated discharge
Penalty
Summary
The facility failed to ensure a comprehensive discharge summary was completed for Resident 35, a resident who had been admitted after living independently at home and sustaining a fall with dislocation of the right shoulder. The resident’s care plan reflected a goal to return home when safe and when care and rehabilitation goals were met. A nursing progress note documented that the resident was discharged home with all belongings and own medications, but the discharge summary-interdisciplinary form contained no documentation of a recapitulation summary of the resident’s stay at the facility. The facility’s discharge summary and plan required that when discharge was anticipated, a discharge summary and post-discharge plan be developed, including a recapitulation of the resident’s stay and a final summary of the resident’s status at discharge. The required summary was to include items such as diagnoses, medical history, course of illness and treatment, test results, functioning, ADL ability, impairments, nutritional status, treatments and procedures, psychosocial status, discharge potential, dental condition, activities potential, rehabilitation potential, cognitive status, and medication therapy. During interview, the DON confirmed that a discharge summary with a recapitulation of the resident’s stay had not been completed when the resident was discharged.
Failure to Complete Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to ensure a Minimum Data Set (MDS) was completed for a resident after admission to hospice. Review of the resident’s physician orders showed hospice admission on 4/28/25, and review of the resident’s quarterly MDS showed cognitive impairment, assistance needed with bed mobility, transfers, toileting, bathing, and dressing, along with neurological conditions including a traumatic brain injury and hospice services. Despite these changes, no MDS assessments were completed after the hospice admission until 7/8/25, and no significant change assessment was completed when the resident was admitted to hospice. The facility’s undated MDS 3.0 Completion policy stated that residents were to be assessed with comprehensive, initial/admission, annual, and significant change assessments, and that disciplines were to follow the current RAI manual for coding each assessment. During interview on 9/3/25 at 11:00 AM, the DON confirmed that the facility had not completed a significant change MDS as required when the resident was admitted to hospice.
Inaccurate MDS Medication Coding
Penalty
Summary
The facility failed to ensure Resident 2's MDS was coded accurately to reflect the medications being administered. Review of the resident's MDS showed the resident had diagnoses including heart disease, hypertension, and fractures, and had received antidepressant, hypnotic, anticoagulant, antibiotic, opioid, and anticonvulsant medications. However, review of the MAR for August 2025 showed no evidence the resident had taken a hypnotic medication, and the care plan showed the resident was admitted following hospitalization for a fall for a rehabilitative stay with a plan to return home. During interview, the DON confirmed Resident 2 was not taking a hypnotic medication and that Section N of the MDS with a reference date of 8/8/25 was not accurately coded. An LPN also confirmed having coded the MDS as if the resident had taken a hypnotic medication, stating the medication was actually an antidepressant and not a hypnotic.
PASARR Screening Not Accurately Completed for Resident with Mental Health Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for one resident. Facility policy stated that all applicants were to be screened for serious mental disorders, intellectual disabilities, and related conditions, and that residents with newly evident or possible serious mental disorders were to be referred for Level II review. Review of the resident’s MDS showed admission with antipsychotic and antianxiety medications and diagnoses of Anxiety and Schizophrenia. The care plan also identified antidepressant and antipsychotic medication use. The resident’s active medication record showed Latuda, an antipsychotic, with a diagnosis of Schizoaffective Disorder and Bipolar disorder. However, the resident’s PASARR dated 8/1/25 did not document that the resident was taking an antipsychotic or had a mental health diagnosis. During interview, the DON confirmed the resident was taking an antipsychotic and had a diagnosis of Schizoaffective disorder with Bipolar that was not indicated on the PASARR and should have been included.
Incomplete Comprehensive Care Plan
Penalty
Summary
Resident 2's comprehensive care plan was not complete or accurate in relation to the resident's diagnoses and medication regimen. The resident's MDS dated 8/8/25 showed admission to the facility with diagnoses including heart disease and fractures, and the resident was receiving antidepressant, hypnotic, anticoagulant, diuretic, opioid, and anticonvulsant medications. However, the care plan with a revision date of 8/26/24 focused on admission after a fall and a plan to return home after rehabilitation, and it did not reflect the resident's use of antidepressant, anticoagulant, diuretic, or anticonvulsant medications or the need to monitor for adverse effects or risks associated with those medications. The care plan also did not address the resident's multiple heart-related diagnoses or include the required monitoring for those conditions. During interview, the DON confirmed that all residents were to have a comprehensive care plan completed after the initial MDS and confirmed that Resident 2's care plan was not comprehensive and did not include black box medication warnings for high-risk medications such as antidepressants, anticoagulants, diuretics, and anticonvulsants.
Failure to Complete AIMS Assessment for Resident Receiving Antipsychotic Medication
Penalty
Summary
The facility failed to complete an assessment for Resident 6 for potential adverse effects from antipsychotic medication. Review of the facility’s psychotropic medication policy showed that residents receiving psychotropic drugs were to have monitoring documented, including an Abnormal Involuntary Movement Scale (AIMS) test on admission, quarterly, with significant change, with antipsychotic medication changes, as needed, or per facility policy. Resident 6’s MDS dated 8/13/25 showed the resident had been admitted, was receiving antipsychotic and antianxiety medications, and had diagnoses of Anxiety and Schizophrenia. Resident 6’s care plan, last revised 8/21/25, documented use of antidepressant and antipsychotic medications. The active medication order summary as of 9/3/25 showed Latuda, an antipsychotic, with a start date of 8/1/25 and diagnoses of Schizoaffective Disorder and Bipolar Disorder. The facility’s AIMS form for Resident 6 dated 8/19/25 was open and had no documentation that the assessment was completed. During interview, the DON confirmed Resident 6 was receiving an antipsychotic medication and that the AIMS assessment had not been completed and should have been completed upon admission.
Hand Hygiene Not Performed Between Wound Care Tasks
Penalty
Summary
The facility failed to ensure hand hygiene was completed at appropriate intervals during wound care for a resident with pressure injuries to the right knee and left great toe. During observation of wound care, an LPN who was also the facility IP entered the resident’s room, put on disposable gloves, set up treatment supplies, and removed foam dressings from both wounds without changing gloves between the wounds. The LPN then disposed of the dressings, changed gloves without performing hand hygiene, and cleaned the left great toe wound with wound cleaner/normal saline on gauze before using the same gloves to clean the right knee wound with normal saline and clean gauze. The LPN again removed gloves, put on clean gloves without sanitizing, and placed clean dressings on both the left great toe and right knee while using the same gloves. Hand hygiene was not performed until after the gloves were removed at the end of the care. The DON confirmed that hand hygiene should be performed after removing gloves and that wound care for both wounds should be treated separately to prevent potential cross-contamination between the wounds. The LPN confirmed using the same gloves while caring for both wounds and confirmed not performing hand hygiene between glove changes.
Failure to Follow Physician Orders for Fluid Consistency
Penalty
Summary
The facility failed to adhere to Resident 1's physician orders regarding fluid consistency, which led to a significant health incident. Resident 1, who had a diagnosis of pneumonitis due to inhalation and moderate cognitive impairment, was supposed to receive honey thick liquids as per the physician's order dated 10/28/24. However, during snack time on 10/26/24, the resident was given thin liquids, resulting in coughing and subsequent hospitalization. The facility's policy on thickened liquids, which outlines the necessity for individuals with swallowing difficulties, was not followed in this instance. Interviews with facility staff confirmed the oversight. The Certified Dietary Manager acknowledged that Resident 1 returned to the facility with an updated order for honey thick liquids, while a Nursing Assistant admitted to providing thin liquids to the resident, leading to the hospital admission. The Director of Nursing also confirmed that the resident was given thin liquids despite having a physician order for thickened liquids. This incident highlights a failure in following prescribed dietary orders, which directly impacted the resident's health and safety.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by multiple observations of staff not following hand hygiene and gloving protocols. Specifically, an LPN was observed performing a finger stick glucose test on a resident without using gloves and failed to clean the glucometer before storing it. The LPN also neglected to perform hand hygiene after handling potentially contaminated items, which included touching various surfaces and equipment in the medication cart area. In another instance, the same LPN did not change gloves or perform hand hygiene between different steps of a procedure involving a gastrostomy tube and wound care for a resident. This included touching a wound dressing with drainage and administering medication through the gastrostomy tube without changing gloves or washing hands. The LPN also touched multiple items in the resident's room with contaminated gloves, further increasing the risk of cross-contamination. Additionally, the facility lacked a water management program to address the risk of Legionella, a bacterium that can cause Legionnaires' disease. The facility also failed to maintain proper infection control measures during COVID-19 testing, as observed by the presence of used test kits and personal information in plain sight without appropriate barriers or PPE. Staff were seen testing themselves for COVID-19 without gloves or barriers, and there was no hand sanitizer or disinfecting wipes available at the testing station.
Non-Functioning Bathroom Ventilation Systems
Penalty
Summary
The facility failed to ensure that the bathroom ventilation systems were functioning properly in 11 out of 12 sampled rooms, specifically rooms 201, 202, 203, 204, 205, 207, 209, 210, 211, 212, and 214. This deficiency was identified through observations conducted on three consecutive days, where it was noted that the ventilation systems did not draw a single square ply of toilet paper, indicating they were not operational. The facility's Maintenance Director confirmed the non-functionality of the ventilation systems and acknowledged that while the systems are checked monthly as a safety measure, there is no documentation to confirm regular checks to ensure they are operational. The facility had a census of 33 at the time of the survey.
Inaccurate MDS Coding for Resident Behaviors
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident, identified as Resident 21, to reflect their behaviors. The MDS is a comprehensive assessment tool used to develop a resident's plan of care. During the survey, it was found that the MDS did not include documented physical and verbal behaviors exhibited by Resident 21 towards staff and other residents, as noted in the nursing progress notes and behavior monthly flow sheets. These behaviors were observed on August 7, 2024, but were not marked on the MDS, which was confirmed by the Licensed Practical Nurse (LPN) responsible for completing the MDS. The Director of Nursing (DON) and the Social Services Director (SSD) confirmed that the MDS should have included these behaviors. The SSD, who completed section E of the MDS, did not review the behavior monthly flow sheets or conduct interviews with family or staff, which contributed to the oversight. Additionally, there was no social service progress note during the assessment period from August 1 to August 8, 2024. This lack of comprehensive assessment and documentation led to the deficiency in accurately reflecting the resident's behaviors in the MDS.
Failure to Plan and Document Resident Discharge
Penalty
Summary
The facility failed to properly plan and document the discharge of a resident, identified as Resident 28, from long-term care to assisted living. The facility's policies, dated December 2016, required a discharge plan to be completed when a discharge is anticipated, and details of the discharge to be documented in the medical record. However, the record review revealed that there was no physician discharge order or completed discharge summary for Resident 28. Additionally, the discharge was not discussed during care plan meetings, and the resident's representative was not involved in any discharge planning or teaching. Resident 28 had a Minimum Data Set (MDS) assessment indicating a Brief Interview for Mental Status (BIMS) score of 14, suggesting mild cognitive impairment. Despite this, the resident's Comprehensive Care Plan (CCP) dated 2/2/18 indicated plans for long-term care placement, with no updates reflecting the discharge to assisted living. Interviews with the Director of Nursing (DON) and the Social Services Director (SSD) confirmed the absence of discharge orders, a transfer sheet, and discharge planning discussions. The resident's representative also confirmed a lack of involvement in discharge planning.
Failure to Train New Employees on Abuse Prevention
Penalty
Summary
The facility failed to ensure that new employees received training on abuse, neglect, and exploitation as part of their initial orientation. This deficiency was identified through record reviews and interviews, revealing that 7 out of 9 sampled employees, who had been employed for less than four months, had no documentation of having completed the required abuse training. The employees in question were hired between January and April 2024. During interviews, the Interim Director of Nursing confirmed that these staff members had not completed the necessary education on abuse. Additionally, the Administrator acknowledged that the expectation was for new employees to complete the abuse training within the first month of employment, but confirmed that the current expectation is for the training to be completed before employees start working on the floor.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 66 citations issued within 25 miles in the last 12 months — 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clarkson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stanton Health Center | 16 mi | ★★★★★ | 2 | 0 |
| Arbor Care Centers-countryside Llc | 18.4 mi | ★★★★★ | 16 | 0 |
| Wisner Care Center | 21.6 mi | ★★★★★ | 0 | 0 |
| Colonial Haven | 21.9 mi | ★★★★★ | 0 | 0 |
| Brookestone Acres | 23 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.