Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clarendon Nursing Home during CMS and state inspections, most recent first.
Expired insulin was found in the medication room, including multiple Humalog, Novolog, and Lantus bottles and pens that had been opened beyond the facility’s 28-day discard guidance, and one Humalog pen had no open date at all. An LVN verified the insulins were still being used for resident treatment, and the DON confirmed insulin should be dated when opened and not used past expiration. Facility records also stated outdated or deteriorated drugs or biologicals shall not be used.
Dietary services staffing was deficient when the facility’s Dietary Manager worked in the role without being certified or enrolled in a certification class. Interviews with the ADS, BOM/HR, ADM, and RD confirmed the DM had been in the position since hire but did not have the required credentials, while the facility policy stated food and nutrition staff must demonstrate the skills and competency to perform department functions.
Food Storage Not Properly Labeled and Dated: Surveyors found multiple pantry, freezer, and refrigerator items stored without labels or dates, including rice, flour, soup cans, frozen items, yogurt, milk, margarine, and meat. Dented cans were also observed on pantry shelves. Staff stated that kitchen staff were responsible for labeling and dating food, and the ADS acknowledged that failure to do so could result in residents receiving incorrect food or becoming sick.
Inaccurate MDS Coding for Insulin Use: A resident with dementia and type 2 DM had an annual MDS that showed insulin use in one section but was coded as not taking insulin in N0415J, despite the care plan and active orders showing Semglee insulin at bedtime. The MDS LVN stated she had not seen insulin included after hypoglycemic before and said she would fix the MDS, while the DON and ADM acknowledged that inaccurate MDS coding could affect funding, care coordination, and resident care.
Failure to include PTSD goals and interventions in a resident’s care plan. A resident with anxiety, bipolar disorder, and PTSD had PTSD listed as an active dx on the MDS, but the care plan did not include trauma-related goals or interventions. A trauma-informed assessment noted nightmares, hypervigilance, and being easily startled, yet it did not provide trauma-specific guidance. The DON confirmed the care plan lacked PTSD-related approaches, and staff interviews showed nursing and activity staff were not aware of the resident’s PTSD or triggers.
The facility did not ensure that an LVN, two CNAs, and a PTA received required training in areas such as Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia, as mandated by facility policy. The BOM/HR was unaware of the training lapses and had not verified training for contracted staff, resulting in incomplete or missing training records.
A CNA provided resident care for two months with an expired certification due to the facility's lack of oversight and absence of a formal system for monitoring staff licensure. Leadership, including the DON and BOM/HR, were unaware of the lapse, and there was no policy in place to ensure certifications were kept current.
The facility failed to meet food service safety standards, with unlabeled and undated food items found in the kitchen, pantry, and freezers. Observations revealed improperly stored and potentially spoiled food, while interviews highlighted a lack of staff training and awareness of food safety protocols. These deficiencies could pose health risks to residents.
The facility failed to conduct quarterly safe smoking assessments for three residents, placing them at risk of burns and injury. These residents, with conditions like traumatic brain injury and dementia, required supervision while smoking. The assessments were not completed due to a change in the assessment form, which did not trigger in the system, leaving a gap in monitoring their ability to smoke safely.
The facility failed to maintain an effective pest control program, leading to a fly infestation over three days. Observations showed that meal trays were not removed promptly, attracting flies and gnats. Residents reported discomfort, and staff acknowledged the issue, but existing pest control measures were insufficient. The facility's policies on maintaining a clean environment were not upheld, affecting residents' quality of life.
A resident's MDS assessment failed to reflect their use of antipsychotic medication and hospice care. Despite records showing the resident received Ariprazole daily and was under hospice care, these were not documented in the MDS. Interviews with facility staff revealed that the LVN responsible for MDS completion did not accurately document the resident's status, potentially impacting care and reimbursement rates.
A facility failed to maintain an effective infection control program when a CNA did not follow proper hand hygiene and glove-changing protocols during incontinent care. The CNA handled a new brief with contaminated gloves after cleaning a resident's rectal area, contrary to the facility's expectations. The DON confirmed that staff were instructed on proper infection control practices, including handwashing and glove changes.
Expired Insulin Stored and Used Beyond Discard Date
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate dispensing and administration of biologicals for 1 of 3 medication storage areas reviewed. During observation of the medication room, 8 insulin products were found with open/accessed dates that showed they had been in use beyond the facility’s documented discard timeframe, and one Humalog insulin pen was not marked with any open/accessed date. The insulin products included Humalog bottles, Novolog bottles, Lantus bottles, Humalog pens, and a Lantus pen, with several opened 29, 33, 41, 44, and 46 days earlier. LVN A verified that all 8 insulins were currently being used for resident treatment. During interview, LVN A confirmed the 8 insulins had expired and stated the facility had an instruction sheet at the nurses’ station identifying when each insulin type should be discarded, usually after 28 or 30 days. LVN A also stated that if expired insulin were given, it could be ineffective or cause a reaction and affect a resident’s blood sugar. The DON stated that all insulins should be dated when opened and expired after about 28 days, and that the facility had an instruction manual at the nurses’ station for medication use and expiration. Record review showed the facility’s insulin guide directed that Humalog, Novolog, Lantus bottles, Humalog KwikPen, and Lantus SoloStar be discarded 28 days after opening, and the facility policy stated that outdated or deteriorated drugs or biologicals shall not be used.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, specifically for 1 of 1 kitchen staff reviewed for qualifications. Record review showed the Dietary Manager’s hire date was 08/01/2025, and interviews confirmed she had been working in the Dietary Manager role since that time without being certified or enrolled in a certification class. During interview, the ADS stated she was not certified and was not enrolled in a class to become certified. The BOM/HR stated she was responsible for making sure staff were trained and confirmed the Dietary Manager was not certified and did not know when classes would start. The ADM stated she believed the Dietary Manager was supposed to be taking classes but later learned she was not enrolled. The RD stated she consulted with the Dietary Manager monthly and more often if needed, but was not sure whether the ADS was certified. The facility policy stated food and nutrition services personnel are to demonstrate the skills and competency to carry out department functions.
Food Storage Not Properly Labeled and Dated
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During observation of the pantry on 01/13/26 at 9:10 AM, surveyors found a clear container of what looked like rice with no label or date, a clear container of what looked like flour with no label, and 3 dented cans of vegetable soup on the pantry shelves. During interview, the ADS stated dented cans were supposed to be kept in a separate area away from food storage, and she then removed the dented cans from the pantry when they were shown to her. Observation of the freezer at 9:15 AM revealed a can of lemonade with no label or date, a box of frozen rolls open to air with a date but no label, 6 individual Italian ices with no label or date, and a box of guacamole packs with no label or date. Observation of the refrigerator at 9:22 AM revealed a container of what appeared to be yogurt with no label or date, an opened container of milk that was 1/4 full with no date, a bag of unidentified meat that was dated but had an unreadable label, a box containing 8 wrapped packages of margarine with no label or date, and a Ziploc bag of meat with no label or date. Staff interviews stated that everyone working in the kitchen was responsible for labeling and dating food, and the ADS stated that failure to do so could put residents at risk for not receiving correct food or getting sick. The facility policy stated dry foods stored in bins must be labeled and dated, all foods stored in the refrigerator or freezer must be covered, labeled, and dated, and wrappers of frozen foods must stay intact until thawing.
Inaccurate MDS Coding for Insulin Use
Penalty
Summary
The facility failed to ensure Resident #36’s assessment accurately reflected his status when the annual MDS was coded to show he was not taking insulin, even though the same assessment also indicated he had received insulin during the 7-day lookback period. Resident #36 was admitted with diagnoses including unspecified dementia with behavioral disturbance, type 2 diabetes mellitus, anxiety disorder, major depressive disorder, and cognitive communication deficit. His MDS, completed on 11/20/25, showed a BIMS score of 00, indicating severely impaired cognition, and Section N0300/N0350 reflected insulin use in the lookback period, while Section N0415J was coded as not taking insulin. The care plan completed on 11/29/25 stated that Resident #36 was taking insulin for diabetes, and the active order summary listed Semglee insulin 10 units subcutaneously at bedtime along with hypoglycemia treatment orders. During interview, the MDS LVN stated she had never seen insulin included after hypoglycemic before and said she would fix the MDS because the resident takes insulin. The DON and ADM stated the MDS LVN was responsible for assessments and acknowledged that an inaccurate MDS could affect funding, continuity of care, team communication, and resident care.
Failure to Include PTSD Goals and Interventions in Care Plan
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident with diagnoses including anxiety disorder, bipolar disorder, and post-traumatic stress disorder (PTSD). The resident’s quarterly MDS completed in December 2025 listed PTSD as an active diagnosis, but the latest revision of the care plan on January 13, 2026 did not include any goals or interventions related to PTSD. A Trauma Informed assessment also documented that the resident had PTSD, experienced nightmares within the past month, and was frequently on guard and easily startled, but it did not include trauma-specific guidance or additional information to assist staff in providing trauma-informed care. During interviews, the MDS LVN stated she and the DON were responsible for updating the care plan with interventions and goals, and the DON confirmed the care plan did not include goals or care approaches related to the resident’s PTSD. The DON also stated she was responsible for completing trauma-related assessments and getting that information into the care plan. Additional staff interviews reflected that nursing and activity staff were not aware of the resident’s PTSD or identified triggers, and the AD stated that documenting care approaches in the care plan helped identify resident-specific triggers and interventions during activities. The resident was observed in activities appearing comfortable and later in bed, and he stated he had PTSD due to events that happened in the military.
Failure to Maintain Required Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, contracted individuals, and volunteers, as required by policy and regulation. Record reviews showed that four out of five employees reviewed (an LVN, two CNAs, and a PTA) did not have up-to-date or complete training in critical areas such as Abuse, Neglect, and Exploitation, Fall Prevention, HIV, Restraints, Emergency Procedures, and Dementia. Specifically, the LVN and two CNAs had not received annual training in these areas since their respective hire or last training dates, and the PTA had no documentation of having received any of the required trainings since hire. During an interview, the BOM/HR acknowledged being unaware that these staff members were not current with their required trainings. She indicated that she had communicated with the corporate office regarding the provision of training and instructional materials but had not addressed the timing of trainings. For the contracted PTA, the BOM/HR assumed the necessary trainings had been completed through the contracting company but had not verified this or obtained documentation. The facility's policy requires specific in-service training upon hire and annually, but records and interviews confirmed this was not consistently implemented.
Failure to Ensure CNA Maintained Current Certification
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) maintained current certification in accordance with state laws. Record review showed that one CNA worked full-time providing resident care for two months with an expired certification. The Business Office Manager/Human Resources (BOM/HR) was unaware of the expired certification and believed it was the employee's responsibility to keep it current. The Director of Nursing (DON) was also unaware of the lapse and confirmed that the CNA had worked during the period of expired certification. The CNA was on bereavement leave at the time of the survey and was not available for interview. Interviews with facility leadership, including the Administrator, DON, Assistant Director of Nursing (ADON), and BOM/HR, revealed there was no established system or policy for regularly reviewing employee certifications or maintaining oversight of licensure status. The Administrator stated that both the DON and BOM/HR, along with the employee, were responsible for ensuring certifications were up to date, but acknowledged the absence of a formal review process. Additionally, monthly in-service trainings were not considered competency training, as they lacked pre- or post-tests and did not measure staff competency.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. The deficiencies included failing to label and date food items in the refrigerator, freezer, and pantry, which could lead to the use of expired or spoiled food. Additionally, food items were not properly sealed, and cleanliness was not maintained in the pantry. The facility also did not store food at least six inches off the floor, as required by regulations. During observations, various food items were found unlabeled and undated, including lunch meat, cheese, pasta, and various cereals. Some items, such as shredded mozzarella cheese, showed signs of spoilage, with green specks present. The pantry was found to have peanut butter smeared on the outside of a container, and several food items were stored directly on the floor, contrary to food safety guidelines. Interviews with staff revealed a lack of training and awareness regarding proper food labeling and storage practices. The Dietary Manager (DM) admitted to not receiving adequate training and was unaware of certain food safety requirements, such as dating food upon opening and storing food off the floor. Other staff members, including the Assistant Director of Nursing (ADON) and the Administrator (ADM), acknowledged the potential health risks associated with these deficiencies, such as foodborne illnesses and inadequate meal quality for residents.
Failure to Conduct Quarterly Safe Smoking Assessments
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for three residents who were reviewed for accidents and hazards. Specifically, the facility did not perform quarterly safe smoking assessments for these residents, which could place them at risk of burns and/or injury. The residents involved had various medical conditions, including traumatic brain injury, dementia, schizophrenia, and lack of coordination, which necessitated supervision while smoking. Resident #2, a male with a history of traumatic brain injury and impaired vision, required supervision while smoking due to lack of coordination and impaired cognition. His care plan indicated the need for supervision, but his safe smoking assessments were not conducted quarterly as required. Similarly, Resident #26, who had severe cognitive impairment and poor safety awareness, also required supervision while smoking. His assessments were not completed quarterly, leaving a gap in monitoring his ability to smoke safely. Resident #39, with moderate cognitive impairment and lack of coordination, was also at risk for injury while smoking. His care plan required supervision, but his assessments were not performed quarterly. Interviews with facility staff revealed that the assessments were not completed due to a change in the assessment form, which failed to trigger in the system. This oversight could lead to residents being unsafe to smoke due to disease progression, as the facility would not be aware of any changes in their condition.
Pest Control Deficiency Due to Ineffective Measures
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an infestation of flies and gnats over a three-day period. Observations revealed that a partially eaten tray of food was left in a resident's room overnight, attracting multiple flies and gnats. This issue was compounded by the fact that meal trays were not consistently removed from resident rooms within the required timeframe, as confirmed by staff interviews. The presence of flies was noted in various locations, including resident rooms and common areas, causing discomfort to residents during meals and daily activities. Residents reported being bothered by the flies, with some attempting to shoo them away during meals. Interviews with staff, including an LVN and the DON, confirmed awareness of the issue, with the DON acknowledging that trays left out could lead to infestations. The facility's pest control measures, including regular pest control services and additional fly control efforts, were documented, but these measures were insufficient to address the ongoing problem. The facility's policies on resident rights and quality of life emphasize the importance of a clean and sanitary environment, which was not upheld in this instance. The failure to promptly remove meal trays and effectively control the fly infestation compromised the residents' quality of life and the facility's ability to provide a safe and homelike environment. Despite efforts to address the issue, the infestation persisted, affecting the residents' daily experiences and comfort.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident, which did not reflect the resident's current status. Specifically, the MDS assessment for a resident did not indicate the use of antipsychotic medication or the resident's enrollment in hospice care. This oversight was identified during a review of the resident's records, which showed that the resident was receiving antipsychotic medication and was under hospice care, contrary to what was documented in the MDS. The resident in question was admitted with several diagnoses, including generalized anxiety disorder, major depressive disorder, and intermittent explosive disorder. The resident's care plan and active orders confirmed the use of antipsychotic medication and hospice care, which were not reflected in the MDS assessment. The resident's medication administration records also showed daily administration of an antipsychotic medication, Ariprazole, which was not documented in the MDS. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Administrator (ADM), and Director of Nursing (DON), revealed that the Licensed Vocational Nurse (LVN) responsible for completing the MDS assessments did not accurately document the resident's medication and care status. The staff acknowledged that an inaccurate MDS could negatively impact the facility's reimbursement rates and potentially affect the resident's care plan. The facility's failure to accurately complete the MDS assessment could lead to inadequate care and services for the resident.
Infection Control Deficiency in Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA B during the provision of incontinent care. During an observation, CNA B did not follow proper hand hygiene and glove-changing protocols. After cleaning a resident's rectal area, CNA B changed gloves and used alcohol-based hand rub (ABHR) but then proceeded to handle a new brief with contaminated gloves. This action was confirmed during an interview with CNA B, who acknowledged not changing gloves or washing hands before placing the clean brief. CNA B also admitted to cleaning the rectal area before the peri area, contrary to the facility's expectations. The Director of Nursing (DON) confirmed that the facility's protocol requires cleaning the peri area before the rectal area to prevent bacterial transmission and expects frequent glove changes and hand hygiene. The facility's policy on hand hygiene, revised in October 2023, emphasizes hand hygiene as the primary means to prevent healthcare-associated infections, specifically indicating the need for hand hygiene before moving from a soiled to a clean body site on the same resident. The DON verified that all direct care staff, including CNA B, were instructed on proper infection control practices, including handwashing and glove changes.
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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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Nursing homes near Clarendon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Memphis Convalescent Center | 23.6 mi | ★★★★★ | 4 | 0 |
| Mclean Care Center | 26.6 mi | ★★★★★ | 1 | 1 |
| Palo Duro Nursing Home | 29.1 mi | ★★★★★ | 0 | 0 |
| Wellington Care Center | 38.4 mi | ★★★★★ | 9 | 1 |
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