Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Health Care during CMS and state inspections, most recent first.
Two residents at risk for pressure ulcers did not receive individualized, consistently monitored pressure ulcer prevention and wound care. One resident with a history of CVA, hemiplegia, immobility, and incontinence was admitted without skin breakdown but later developed large suspected deep tissue injuries to the coccyx that progressed to an unstageable ulcer requiring surgical debridement, while her care plan interventions for pressure ulcer risk remained unchanged from admission despite ongoing moderate Braden scores. Another resident admitted with existing stage II and stage III buttock pressure injuries developed two additional stage II ulcers, and after the initial documentation of these new wounds, no further wound measurements or characteristics were recorded. Staff interviews revealed reliance on paper sheets for repositioning with only a single EMR checkmark per shift, lack of a defined process for regular wound assessments, and generic care plan interventions, all of which conflicted with the facility’s own skin care/pressure ulcer policy requiring individualized interventions and weekly detailed wound documentation.
A resident was allowed to self-administer nebulizer medications without a documented assessment or care plan for self-administration, contrary to facility policy. An LPN set up the nebulizer and left the resident alone during the treatment, and interviews confirmed that no residents had been assessed for safe self-administration of medications.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not consistently inspect bed frames, mattresses, and bed rails for safety, and failed to ensure that bed rails and mattresses were securely attached to the bed frame as required.
Failure to individualize and monitor pressure ulcer prevention and wound care
Penalty
Summary
The deficiency involves the facility’s failure to provide resident-centered pressure ulcer prevention and monitoring for two residents at risk for skin breakdown. One resident was admitted without skin conditions but had a history of cerebral infarction with right-sided hemiplegia, immobility, and incontinence, and was identified as having a moderate risk for pressure ulcers based on Braden scores ranging from 14 to 16 during the first four weeks after admission. On admission, her sacral and coccyx areas were documented as pink and blanchable. On a later date, an RN documented two non-blanchable suspected deep tissue pressure injuries to the coccyx, with large areas measuring 17 cm x 25 cm and 8 cm x 7 cm, described as dark maroon and slightly boggy. A repositioning schedule every two hours was initiated and the physician and POA were notified, and a mepilex dressing was ordered and later modified, but the resident’s baseline care plan problem and interventions for pressure ulcer risk were not revised from admission through the identification of the coccyx wound and up to her hospital transfer. Subsequent nursing documentation for this resident showed that the coccyx wound progressed to an unstageable pressure ulcer with 100% black, dry, firmly adherent eschar measuring approximately 8 cm x 3 cm. The skin nurse consulted the contracted wound specialist and physician, and a treatment with medihoney and daily dressing changes was ordered. The resident later developed a fever and was sent to the emergency room for evaluation of possible infection related to the coccyx wound, where imaging and surgical evaluation identified surrounding cellulitis and reactive edema in the coccyx, and a debridement with bone biopsy revealed multiple bacteria. Throughout this period, despite ongoing moderate Braden risk scores and the development and progression of the coccyx wound, the resident’s care plan interventions for pressure ulcer risk remained unchanged from the original admission plan. The second resident was admitted with two stage II pressure ulcers on the left buttock, measuring 0.5 cm x 0.5 cm and 3 cm x 5 cm, and had a care plan problem for potential pressure ulcers related to immobility, incontinence, and neuropathy. Her care plan also listed existing pressure injuries to both buttocks at stage III, with approaches including turning and repositioning, assessing and documenting ulcer condition per facility protocol, and treating per protocol. A nursing progress note a few days after admission documented two new open pressure injuries on the left buttock, each measuring 1 cm x 0.5 cm. However, after this entry, there were no further documented wound measurements or characteristics such as size, color, drainage, odor, or other assessment details in the EMR. Interviews with staff revealed additional process failures related to pressure ulcer prevention and monitoring. CNAs reported that they relied on daily paper sheets to track repositioning and could only enter a single checkmark per shift in the EMR to indicate that repositioning every two hours had been done, without documenting each individual turn. The DON stated that CNAs were expected to document two-hour turns in the EMR and that nurses were expected to document refusals, but she was unaware that CNAs were limited to a single checkmark per shift. The DON also acknowledged that residents admitted with risk for pressure ulcers had the same care plan interventions, that care plans were expected to reflect skin concerns found on admission, and that there was no established process for completion of resident wound assessments. She further acknowledged that documenting a dressing change was not the same as documenting a wound assessment and that she would have expected weekly wound assessments and care plan updates when additional pressure injuries were identified, which did not occur for the residents involved. Review of the facility’s Skin Care/Pressure Ulcer policy showed that all residents were considered at risk upon admission and that interventions such as pressure-reducing mattresses, full-body skin assessments, dietician review, and individualized care plan interventions were required. The policy also required assessment of pressure ulcers for type, stage, characteristics, progress toward healing, infection, pain, dressings or treatments, and physician notification if there was no improvement in two to three weeks, as well as weekly documentation of detailed wound characteristics. The documented care and records for the two residents did not reflect consistent implementation of these policy requirements, including individualized care planning, regular wound assessments, and complete documentation of wound status and repositioning.
Failure to Assess Resident for Safe Self-Administration of Nebulizer Medications
Penalty
Summary
A deficiency occurred when a resident was observed self-administering nebulizer medications without a documented assessment of their ability to do so safely, as required by facility policy. During a medication pass, an LPN prepared and set up the resident's nebulizer treatment, placed the mask on the resident, and then left the room, stating she would return after the treatment was complete. The LPN confirmed that by leaving the resident alone, the resident was self-administering the medication, and she could not verify that the full dose was taken. The LPN also stated she was unaware of any completed assessment for the resident's ability to self-administer medications. Review of the resident's medical record showed no physician's order for self-administration, no completed self-administration assessment, and no mention of self-administration in the care plan. Interviews with the resident, the DON, and the administrator confirmed that no residents in the facility had been assessed for safe self-administration of medications, and the expectation was that staff should remain with residents during nebulizer treatments unless an assessment had been completed. Facility policy requires an interdisciplinary team assessment and care plan documentation before allowing self-administration of medications, which was not followed in this case.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled according to currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions represent a failure to follow proper labeling and storage protocols for medications and biologicals within the facility.
Failure to Ensure Safe Inspection and Attachment of Bed Equipment
Penalty
Summary
The facility failed to regularly inspect all bed frames, mattresses, and bed rails for safety. Additionally, bed rails and mattresses were not ensured to be safely attached to the bed frame as required. This deficiency was identified through direct observation and review of facility practices regarding the maintenance and safety checks of beds and related equipment.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Arrowhead | 0.5 mi | ★★★★★ | 20 | 0 |
| Avantara Mountain View | 1.8 mi | ★★★★★ | 10 | 0 |
| Avantara Saint Cloud | 2.6 mi | ★★★★★ | 6 | 0 |
| Good Samaritan Society - St Martin Village | 3.1 mi | ★★★★★ | 3 | 0 |
| Westhills Village Health Care Facility | 3.1 mi | ★★★★★ | 3 | 0 |
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