Inspection Reports for
Clarence Care Center
111 EAST ST, CLARENCE, MO, 63437-1902
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
16.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
200% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
57% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Nov 17, 2025
Visit Reason
The inspection was conducted due to a complaint involving a Certified Nurse Aide (CNA) who gave a resident access to a marijuana vape pen and was under the influence of marijuana while on duty.
Complaint Details
The complaint involved CNA A giving Resident #5 a puff from a marijuana vape pen and being under the influence of marijuana while on duty. The incident was reported late to administration. CNA A was suspended and educated. The resident's physician was not notified as expected.
Findings
The facility failed to ensure protective oversight for Resident #5 when CNA A allowed the resident to inhale marijuana from the CNA's vape pen and failed to immediately report the CNA's impairment to administration. The CNA was suspended and educated on policy violations. Medication interactions with cannabis were noted as potentially harmful.
Deficiencies (1)
Failed to ensure protective oversight when CNA gave resident access to marijuana vape pen and was under the influence while on duty.
Report Facts
Residents affected: 6
Census: 34
Medication doses: 15
Medication doses: 20
Medication doses: 20
Medication doses: 1000
Medication doses: 150
Medication doses: 75
Medication doses: 25
Medication doses: 2
Suspension duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in findings for giving resident marijuana vape pen and being under influence while on duty |
| CNA D | Certified Nurse Aide | Assisted CNA A and reported incident |
| CNA B | Certified Nurse Aide | Assisted CNA A and reported incident |
| CNA C | Certified Nurse Aide | Reported CNA A's impairment to Director of Nursing |
| CNA G | Certified Nurse Aide | Reported hearing CNA A was high |
| CMT I | Certified Medication Technician | Reported hearing CNA A was high |
| Director of Nursing | Director of Nursing | Received reports and suspended CNA A |
| Administrator | Administrator | Oversaw disciplinary action and policy enforcement |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: May 21, 2024
Visit Reason
The inspection was conducted due to allegations of financial exploitation and sexual abuse of one resident (Resident #401) in a sample of nine residents.
Complaint Details
The complaint involved allegations of financial exploitation and sexual abuse of Resident #401. The allegations were substantiated as the facility failed to report and fully investigate the incidents. Multiple employees had inappropriate financial interactions with the resident, and a Certified Nurse Assistant was alleged to have received gifts and engaged in a sexual relationship with the resident while employed by the facility.
Findings
The facility failed to report allegations of financial exploitation and sexual abuse to the state agency, and failed to fully investigate these allegations. Multiple employees had financial interactions with the resident, including purchasing property sold below market value and charging higher rates for services. The facility did not document all actions related to the allegations, did not interview other residents, and did not document actions to prevent further abuse.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to fully investigate allegations of financial exploitation and sexual abuse, including lack of documentation and failure to interview other residents.
Report Facts
Facility census: 33
Sample size: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) I | Alleged to have received gifts and engaged in a sexual relationship with the resident while employed by the facility |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Jan 25, 2024
Visit Reason
The investigation was conducted due to allegations of financial exploitation and sexual abuse of Resident #401 by multiple facility employees, including inappropriate financial transactions and a possible sexual relationship.
Complaint Details
The complaint involved allegations of financial exploitation and sexual abuse of Resident #401 by multiple employees, including CNA I and RN A. The facility failed to report these allegations timely and did not fully investigate or document the findings. CNA I was terminated for an inappropriate relationship with the resident. RN A purchased the resident's camper below market value. Other employees were paid by the resident for services such as house cleaning. The facility census was 33.
Findings
The facility failed to timely report suspected abuse and neglect, failed to fully investigate allegations of financial exploitation and sexual abuse, and did not document all actions related to the allegations. Multiple employees had financial interactions with the resident, including purchasing property below market value and receiving payment for services at higher rates. The facility also failed to prevent further abuse and did not follow policies regarding staff relationships with residents.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to fully investigate allegations of financial exploitation and sexual abuse, did not document all actions, did not interview other residents, and did not document actions to prevent further abuse.
Report Facts
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA I | Certified Nurse Assistant | Named in findings related to sexual relationship and financial exploitation with Resident #401 |
| RN A | Registered Nurse | Named in findings related to purchase of resident's camper below market value |
| CNA B | Certified Nurse Assistant | Interviewed regarding allegations of sexual relationship |
| Dietary Aide C | Dietary Aide | Involved in renting resident's house and financial interactions |
| Housekeeper L | Housekeeper | Hired by resident for house cleaning |
| Housekeeper M | Housekeeper | Hired by resident for house cleaning |
| Administrator | Facility Administrator | Involved in investigation and decisions related to allegations |
| Director of Nursing | Director of Nursing | Involved in investigation and decisions related to allegations |
Inspection Report
Life Safety
Census: 30
Capacity: 60
Deficiencies: 1
Date: Jan 24, 2024
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found to be in noncompliance with NFPA 96 standards due to a 1-inch by ½-inch unsealed hole in the kitchen exhaust hood, which could affect occupants in the main dining room. The facility failed to ensure the kitchen exhaust hood was free of holes as required.
Deficiencies (1)
K 324 Cooking Facilities: The facility failed to ensure the kitchen exhaust hood was free of holes in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Observation showed a 1-inch by ½-inch unsealed hole in the lower right corner of the kitchen exhaust hood.
Report Facts
Facility capacity: 60
Census: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed the hole in the kitchen's exhaust hood system during interview |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 4
Date: Jul 1, 2021
Visit Reason
The inspection was conducted due to allegations of abuse and neglect involving residents at Clarence Care Center. The investigation focused on verifying the facility's compliance with resident rights and freedom from abuse.
Complaint Details
The complaint investigation was substantiated. The facility was found to have failed in protecting residents from abuse and neglect, including verbal and physical abuse by a Certified Nurse Assistant and failure to report and manage the abuse allegations properly.
Findings
The facility failed to ensure one resident was treated with dignity and respect and failed to prevent verbal and physical abuse by a Certified Nurse Assistant. The facility also failed to implement adequate abuse policies and procedures to protect residents during and after an abuse investigation.
Deficiencies (4)
F557 Respect, Dignity/Right to have Personal Property. The facility failed to ensure staff treated one resident with dignity and respect, as evidenced by verbal abuse and inappropriate behavior by a Certified Nurse Assistant.
F600 Free from Abuse and Neglect. The facility failed to ensure one resident was free from verbal and physical abuse by a staff member, and the resident was fearful and upset after the incident.
F607 Develop/Implement Abuse/Neglect Policies. The facility failed to implement abuse policies to protect residents during and after an abuse investigation, including placing the involved staff member on leave.
F609 Reporting of Alleged Violations. The facility failed to report allegations of abuse to the state survey agency within the required two-hour timeframe after the incident was made known.
Report Facts
Facility census: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nurse Assistant | Named in findings related to verbal and physical abuse of residents |
| RN I | Registered Nurse | Completed employee counseling form and involved in interviews regarding abuse incidents |
| CNA H | Certified Nurse Assistant | Reported incident to RN I involving resident abuse |
| Director of Nursing | Director of Nursing | Provided statements regarding staff monitoring and attitudes toward residents |
Inspection Report
Routine
Census: 36
Deficiencies: 8
Date: May 27, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident trust fund management, transfer and discharge notifications, bed hold policies, CPR certification, pressure ulcer care, fall prevention, facility-wide resource assessment, and antibiotic stewardship.
Findings
The facility was found deficient in multiple areas including failure to provide quarterly statements for resident trust funds, failure to notify residents and Ombudsman of transfers, failure to inform residents of bed hold policies at transfer, lack of CPR certified staff for resident transport, inadequate pressure ulcer care and documentation, insufficient fall prevention interventions and care plan updates, lack of a facility-wide resource assessment, and failure to implement an antibiotic stewardship program.
Deficiencies (8)
Failed to provide quarterly statements of resident trust funds to all residents or their representatives, including those with petty cash balances.
Failed to provide timely notification to residents, representatives, and Ombudsman of hospital transfers for five residents.
Failed to inform residents or representatives in writing of the facility's bed hold policy at the time of hospital transfer for five residents.
Failed to develop and implement CPR policy and ensure CPR certified staff were available during resident transport in facility van.
Failed to obtain physician orders for treatment of Stage II pressure ulcers and failed to consistently assess and document skin and pressure ulcer risk for two residents.
Failed to implement and evaluate fall prevention interventions and update care plans after multiple falls for two residents; failed to provide adequate supervision for a resident while smoking.
Failed to conduct and document a facility-wide assessment to determine necessary resources for competent resident care during day-to-day operations and emergencies.
Failed to develop an antibiotic stewardship program including protocols and monitoring of antibiotic use.
Report Facts
Facility census: 36
Residents on antibiotics: 17
Residents reviewed: 12
Residents affected by transfer notification deficiency: 5
Residents affected by bed hold policy deficiency: 5
Residents affected by CPR deficiency: 2
Residents affected by pressure ulcer deficiency: 2
Residents affected by fall prevention deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Transportation Staff H | Transportation Staff | Named in CPR certification deficiency and transport of residents #33 and #35 |
| RN A | Registered Nurse | Involved in pressure ulcer assessment and fall prevention |
| CNA G | Certified Nurse Aide | Found open pressure ulcer area on resident #15 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding CPR certification, antibiotic stewardship, and fall prevention |
| Administrator | Facility Administrator | Interviewed regarding transfer notification, bed hold policy, facility assessment, and antibiotic stewardship |
| Community Coordinator | Interviewed regarding transfer notification and bed hold policy | |
| Social Services/Activity Director | Interviewed regarding transfer notification | |
| Certified Medication Technician E | Certified Medication Technician | Involved in pressure ulcer care |
| Certified Nurse Aide C | Certified Nurse Aide | Observed resident with pressure ulcer |
| Certified Nurse Aide F | Certified Nurse Aide | Interviewed about pressure ulcer and fall prevention |
| Certified Nurse Aide D | Certified Nurse Aide | Interviewed about resident fall frequency |
Inspection Report
Re-Inspection
Census: 36
Deficiencies: 14
Date: May 27, 2021
Visit Reason
The inspection was a re-inspection to verify correction of previously cited deficiencies related to accounting and records of personal funds, notice requirements before transfer/discharge, CPR certification, pressure ulcer treatment, and other regulatory compliance issues.
Findings
The facility was found deficient in multiple areas including failure to provide quarterly statements of resident trust funds, failure to notify residents and Ombudsman of transfers and discharges, lack of CPR certified staff, inadequate pressure ulcer treatment and documentation, and failure to implement an antibiotic stewardship program. Plans of correction were submitted to address these issues.
Deficiencies (14)
F568 Accounting and Records of Personal Funds. The facility failed to provide quarterly statements of the resident trust funds account to residents or their representatives. The facility census was 36.
F623 Notice Requirements Before Transfer/Discharge. The facility failed to provide written notice of transfer or discharge to residents, representatives, and the Ombudsman for multiple residents. The facility census was 36.
F625 Notice of Bed Hold Policy Before/Upon Transfer. The facility failed to inform residents and representatives of the bed hold policy at the time of transfer for five residents. The facility census was 36.
F678 Cardio-Pulmonary Resuscitation (CPR). The facility failed to ensure CPR certified staff were trained and available, including during resident transport. The facility census was 36.
F686 Treatment/Services to Prevent/Heal Pressure Ulcers. The facility failed to obtain physician orders for treatment of a Stage II pressure ulcer and failed to consistently assess and document residents' skin condition. The facility census was 36.
F689 Free of Accident Hazards/Supervision/Devices. The facility failed to evaluate and monitor falls risk and provide adequate supervision for residents with a history of falls. The facility census was 36.
F838 Facility Assessment. The facility failed to conduct and document a comprehensive facility-wide assessment to determine resources necessary for resident care. The facility census was 36.
F881 Antibiotic Stewardship Program. The facility failed to establish an infection prevention and control program that included antibiotic stewardship. The facility census was 36.
A4029 Communicable Disease-Employees. The facility failed to ensure all employees were screened for tuberculosis according to regulations. The facility census was 36.
A4073 Protective Oversight, Voluntary Leave. The facility failed to provide twenty-four hour protective oversight for residents on voluntary leave.
A4074 Nursing Care per Resident Condition. The facility failed to provide personal attention and nursing care consistent with residents' conditions.
A4082 Pressure Sore Prevention/Treatment. The facility failed to prevent and treat pressure sores adequately.
A8008 Informed Services/Charges - Alzheimer’s Disclosure. The facility failed to fully inform residents or representatives of services and charges related to Alzheimer’s care.
A8043 Resident Funds-Written Statement. The facility failed to provide written statements of resident funds as required.
Report Facts
Facility census: 36
Facility census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy Harre | Administrative Assistant | Named in plan of correction communication |
| Janet McCoy | Community Relations Coordinator | Named in plan of correction communication |
| Jessica Rogaliski | Ombudsman Coordinator | Named in plan of correction communication |
| Crystal Plank | Clinical Educator | Named in plan of correction for fall interventions and wound prevention |
Inspection Report
Life Safety
Census: 36
Capacity: 60
Deficiencies: 24
Date: May 24, 2021
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations and related emergency preparedness requirements.
Findings
The facility was found to have multiple deficiencies related to fire safety, including failure to maintain fire resistance ratings, improper locking mechanisms on egress doors, inadequate sprinkler system maintenance, and issues with emergency preparedness plans and training.
Deficiencies (24)
K161: The facility failed to maintain the required fire resistance rating of barrier penetrations, allowing unsealed openings that could affect fire compartments.
K222: Egress doors were found with delayed egress locking systems not meeting NFPA 101 requirements, and some doors were locked or could not be opened manually during emergency conditions.
K321: Hazardous areas were not protected by a fire barrier or self-closing doors, potentially affecting 21 residents in five smoke compartments.
K353: The sprinkler system was not maintained properly, with heavy buildup of fuzzy debris in multiple sprinkler heads throughout the facility.
K372: Smoke barriers had multiple penetrations and openings not properly sealed, compromising fire resistance and smoke containment.
K374: Smoke barrier doors were not maintained to be self-closing and latching as required, with gaps and missing closers noted.
K712: Fire drills were not conducted as required, with incomplete documentation and failure to simulate actual fire conditions.
K918: The emergency power system was not inspected or maintained annually as required, and documentation was missing.
K920: Electrical equipment and power cords were not assessed annually for safety, and safety documentation was lacking.
K923: Gas equipment storage was not properly maintained or labeled, with combustible materials stored improperly and tanks not secured.
E004: The facility failed to develop and maintain an emergency preparedness plan that is reviewed and updated annually.
E006: The emergency preparedness plan lacked required elements including risk assessment and strategies for emergency events.
E013: Policies and procedures for emergency preparedness were not reviewed or updated at least every two years as required.
E015: The facility failed to provide adequate subsistence needs for staff and patients during emergencies, including food, water, and alternate energy sources.
E018: The facility failed to develop and maintain a communication plan for emergencies that includes all required elements and contact information.
E020: The emergency preparedness plan did not include procedures to track staff and sheltered patients during emergencies.
E024: The facility failed to develop policies and procedures to address surge capacity and emergency staffing in a crisis.
E026: The facility failed to develop policies and procedures for care and treatment of residents placed at alternative sites during emergencies.
E030: The facility failed to maintain and update the emergency operations plan and keep it accessible to staff and residents.
E032: The facility failed to include a primary and alternate means for emergency communication in the emergency preparedness plan.
E033: The facility failed to include methods for sharing information and medical documentation during emergencies in the emergency preparedness plan.
E035: The facility failed to identify a method for providing information to residents and representatives during emergencies.
E037: The facility failed to provide emergency preparedness training to all staff and volunteers at least every two years.
E041: The facility failed to maintain emergency power systems and fuel supply to ensure continuous operation during emergencies.
Report Facts
Facility census: 36
Facility capacity: 60
Deficiencies cited: 26
Inspection Report
Routine
Deficiencies: 0
Date: Dec 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 11, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 11
Date: Apr 4, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including resident self-determination, baseline care planning, wound care, pain management, and food safety. Several residents' rights and care plans were not properly addressed or documented.
Deficiencies (11)
F561 Self-determination. The facility failed to ensure residents' rights to choose schedules and make life choices were respected and documented.
F655 Baseline Care Plan. The facility failed to develop and implement baseline care plans for residents including necessary healthcare information and summaries.
F684 Quality of Care. The facility failed to provide adequate wound care and treatment consistent with residents' needs and failed to notify physicians of new wounds.
F697 Pain Management. The facility failed to maintain an effective pain management program and adequately assess and document residents' pain.
F803 Menus and Nutritional Adequacy. The facility failed to follow recipes and menus and did not serve food items as directed.
F812 Food Procurement, Store, Prepare, Serve, Sanitary. The facility failed to maintain ice machine sanitation and proper air gap to prevent contamination.
A6009 Air Ducts-Maintain. The facility failed to maintain intake and exhaust air ducts to prevent contamination.
A7042 Ice Store/Dispense, No Contamination, Air Gap. The facility failed to prevent contamination of ice storage and dispensing equipment.
A8042 Resident Lives Not Regulated/Controlled. The facility failed to regulate residents' personal lives and safety adequately.
A4074 Nursing Care per Resident Condition. The facility failed to provide personal attention and nursing care consistent with residents' conditions.
A5001 Nutritional Needs Met, Assess Resident, Inform Doctor. The facility failed to meet nutritional needs and properly assess residents.
Report Facts
Facility census: 31
Inspection Report
Life Safety
Census: 31
Capacity: 60
Deficiencies: 15
Date: Apr 4, 2019
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with emergency preparedness, fire safety, and related health and safety regulations.
Findings
The facility was found deficient in emergency preparedness policies, tracking of staff and residents during emergencies, emergency power system inspection and fuel supply, illumination of means of egress, sprinkler system installation and maintenance, smoke barrier door frames, HVAC ductwork cleanliness, smoking regulations, and electrical system safety. The facility census was 31 with a licensed capacity of 60 beds.
Deficiencies (15)
E018: The facility failed to maintain an emergency preparedness plan including a system to track the location of on-duty staff and sheltered residents during an emergency. The facility census was 31.
E041: The facility failed to develop and maintain an emergency power system inspection, testing, and maintenance plan including an emergency fuel supply agreement. The facility census was 31.
K281: The facility failed to ensure exit discharge lighting was operational in designated emergency exits affecting 15 residents. The facility capacity was 60 and census was 31.
K351: The facility failed to install and maintain a complete sprinkler system as required by NFPA 101, affecting occupants in one of five smoke compartments. The facility capacity was 60 and census was 31.
K353: The facility failed to ensure sprinklers were free of foreign material that could affect operation, impacting all occupants in five smoke compartments. The facility capacity was 60 and census was 31.
K374: The facility failed to install fire-rated door frames in smoke barriers, potentially affecting residents in four of five smoke compartments. The facility capacity was 60 and census was 31.
K521: The facility failed to maintain HVAC ductwork free of dust and waste materials, posing a fire hazard in two of five smoke compartments. The facility capacity was 60 and census was 31.
K741: The facility failed to maintain smoking areas free of fire hazards, including self-closing cans and ashtrays, affecting all occupants. The facility capacity was 60 and census was 31.
K911: The facility failed to maintain electrical wiring in compliance with the National Electrical Code, including unprotected splices and blocked electrical panels, affecting occupants in multiple areas. The facility capacity was 60 and census was 31.
A1132: The facility failed to provide functioning night-lights in resident rooms and adjacent areas. The facility census was 31.
A2032: The facility did not have a complete sprinkler system as required for facilities licensed prior to August 28, 2007. This regulation is not met as evidenced by Class II deficiency.
A2034: The facility failed to inspect, maintain, and test sprinkler systems in accordance with requirements. This regulation is not met as evidenced by Class II deficiency.
A2054: The facility failed to maintain smoke section walls and doors with required fire ratings. This regulation is not met as evidenced by Class II deficiency.
A2057: The facility failed to provide proper ashtrays of noncombustible material and safe disposal in designated smoking areas. This regulation is not met as evidenced by Class III deficiency.
A3030: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70, 1999 edition. This regulation is not met as evidenced by Class II deficiency.
Report Facts
Facility census: 31
Total licensed capacity: 60
Deficiencies cited: 14
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 6
Date: Apr 4, 2019
Visit Reason
The inspection was conducted based on complaints regarding resident rights to self-determination, baseline care plan summaries, wound care, pain management, dietary menu compliance, and food safety concerns.
Complaint Details
The complaint investigation focused on issues related to resident rights, baseline care plan communication, wound care, pain management, dietary compliance, and food safety. The facility census was 31 residents.
Findings
The facility failed to ensure residents' rights to choose schedules, provide baseline care plan summaries to residents and representatives, provide appropriate wound care and monitoring, maintain effective pain management, follow dietary recipes and menus for special diets, and maintain proper food safety standards including ice machine drainage and kitchen exhaust vent cleanliness.
Deficiencies (6)
Failed to ensure residents' right to choose schedules and make choices about their lives, including waking times.
Failed to provide residents and their representatives with a summary of the baseline care plan within 48 hours of admission.
Failed to provide wound treatment and care according to orders and failed to monitor wounds consistently.
Failed to provide safe and appropriate pain management, including inadequate pain assessment and documentation, and failure to provide timely pain medication.
Failed to follow recipes and menu specifications for mechanical soft and pureed diets, including incorrect portion sizes and missing components.
Failed to ensure ice machine had an appropriate air gap to prevent back siphonage and failed to maintain the exhaust vent over the dish machine in the kitchen.
Report Facts
Residents on mechanical soft diet: 12
Residents on pureed diet: 2
Portion size served: 0.2
Portion size served: 0.2
Portion size served: 0.17
Portion size served: 0.2
Facility census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA O | Certified Nurse Assistant | Named in findings related to resident waking times and care |
| CNA J | Certified Nurse Assistant | Named in findings related to resident waking times and care |
| CNA L | Certified Nurse Assistant | Named in findings related to resident waking times and care |
| LPN H | Licensed Practical Nurse, Night Shift Charge Nurse | Named in findings related to resident waking times and pain management |
| CMT/MDS Coordinator | Certified Medication Technician / MDS Coordinator | Named in findings related to wound care and pain management |
| DON | Director of Nursing | Named in findings related to resident waking times, wound care, and pain management |
| RN A | Registered Nurse | Named in findings related to wound care and blister management |
| CMT D | Certified Medication Technician | Named in findings related to pain management |
| Dietary Staff B | Dietary Staff | Named in findings related to food preparation and serving |
| Dietary Manager | Dietary Manager | Named in findings related to food preparation and serving |
| Maintenance Supervisor | Maintenance Supervisor | Named in findings related to ice machine drainage and kitchen exhaust vent |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 7
Date: Jun 5, 2018
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for nursing care, infection control, nutrition, and other resident care standards at Clarence Care Center.
Findings
The facility was found deficient in multiple areas including care plan timing and revision, infection control, nutritional needs, medication administration, and immunization policies. Deficiencies were documented with specific resident cases and regulatory citations.
Deficiencies (7)
F657 Care Plan Timing and Revision: The facility failed to develop and update or revise care plans consistent with residents' specific conditions and risks for three residents, including failure to address elopement risk and use of wander guard devices.
F658 Services Provided Meet Professional Standards: The facility failed to follow professional standards when administering eye drops to one resident, including improper application technique and timing.
F692 Nutrition/Hydration Status Maintenance: The facility failed to maintain acceptable nutritional parameters for one resident who experienced significant weight loss and did not implement timely interventions.
F803 Menus Meet Resident Needs/Prep In Advance/Followed: The facility failed to serve correct portion sizes and maintain food safety standards for ten residents on a mechanical soft diet.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to thaw food using safe practices, maintain clean flooring in the dish area, and ensure proper cooling of cooked turkey breast.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention program, including failure to use appropriate hand hygiene during medication administration for eight residents.
F883 Influenza and Pneumococcal Immunizations: The facility failed to provide influenza and pneumococcal vaccinations or document refusals for multiple residents.
Report Facts
Facility census: 36
Weight loss percentage: 12.87
Weight loss percentage: 10.73
Weight loss percentage: 4.86
Weight loss in pounds: 22.8
Weight loss in pounds: 8.6
Weight loss in pounds: 9
Weight: 177.1
Weight: 168.5
Weight: 158.1
Weight: 154.3
Weight: 154
Temperature: 193
Temperature: 196.5
Temperature: 140.3
Inspection Report
Life Safety
Census: 36
Capacity: 60
Deficiencies: 4
Date: Jun 5, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations, including cooking facilities, smoke barriers, and heating systems.
Findings
The facility failed to maintain the kitchen range hood in accordance with NFPA 96, had incomplete smoke barriers with unsealed penetrations and defective smoke barrier doors, and failed to prohibit the use of portable space heaters. These deficiencies had the potential to affect residents, visitors, and staff.
Deficiencies (4)
K324 Cooking Facilities: The facility failed to maintain the kitchen range hood in accordance with NFPA 96. The duct tape covering openings was present for an unknown duration, potentially affecting residents and staff.
K372 Smoke Barrier Construction: The facility failed to ensure smoke barriers were complete and sealed, with multiple unsealed penetrations and holes compromising smoke containment.
K374 Smoke Barrier Doors: The facility failed to ensure smoke barrier doors resisted smoke passage, with visible gaps compromising egress and fire safety.
A3027 Heating System: The facility failed to prohibit the use of portable space heaters, with observed heaters in the nursing office and administrator's office.
Report Facts
Facility capacity: 60
Census: 36
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