Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 12, 2025
Visit Reason
An investigation of complaint #2617924-C was conducted on November 12, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #2617924-C was investigated and found to be unsubstantiated as the facility was in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 4, 2025
Visit Reason
This document is a plan of correction related to a previous survey ending July 9, 2025, addressing substantial compliance and corrective actions for the facility.
Findings
The facility is certified in compliance effective July 30, 2025, based on acceptance of the credible allegation of substantial compliance and the submitted Plan of Correction.
Deficiencies (1)
| Description |
|---|
| Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction for the survey ending July 9, 2025. |
Report Facts
Certification effective date: Jul 30, 2025
Survey end date: Jul 9, 2025
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 1
Jul 9, 2025
Visit Reason
The inspection was conducted as an annual recertification survey from July 7, 2025 to July 9, 2025 to assess compliance with federal regulations.
Findings
The facility failed to complete and sign admission, quarterly, and discharge resident assessments within the required timeframes for 3 of 3 residents reviewed, resulting in numerous unsigned items and late submissions. The facility reported a census of 42 residents at the time of the survey.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete and sign admission, quarterly, and discharge resident assessments within required timeframes. | SS = D |
Report Facts
Residents reviewed: 3
Unsigned MDS items: 98
Unsigned MDS items: 284
MDS errors: 222
Census: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Tjaden | Administrator | Signed plan of correction and referenced in interview regarding MDS schedule |
| Director of Nursing | Mentioned in interview reporting MDS Coordinator busy but no full name provided | |
| MDS Coordinator | Interviewed regarding MDS completion and submission but no full name provided |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 10, 2025
Visit Reason
A complaint investigation was conducted for facility reported incidents #126052-I and #127200-I on April 9-10, 2025.
Findings
The facility was found to be in substantial compliance following the complaint investigation.
Complaint Details
Investigation of complaints #126052-I and #127200-I; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 13, 2024
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, leading to certification in compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification effective September 13, 2024.
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 2
Aug 19, 2024
Visit Reason
The inspection was conducted as an annual recertification survey of the facility from August 19, 2024 to August 22, 2024.
Findings
The facility failed to meet requirements related to the Quality Assessment and Assurance/Quality Assurance and Performance Improvement (QAPI) committee and Infection Prevention and Control program. Deficiencies included lack of required Infection Preventionist participation in QAPI meetings and failure to follow Enhanced Barrier Precautions during tube feeding for one resident.
Deficiencies (2)
| Description |
|---|
| Facility failed to have the required Infection Preventionist at 2 of 2 QAPI meetings and incomplete sign-in sheets for Infection Preventionist. |
| Facility failed to wear appropriate Personal Protective Equipment (PPE) during tube feeding for Resident #38, violating Enhanced Barrier Precautions. |
Report Facts
Census: 45
Dates of QAPI sign-in sheets: 3/21/24 and 6/6/24
Date of Physician's order: 6/28/24 for Resident #38
Date of Care Plan intervention: 8/19/24 for Resident #38
Date of observation of PPE failure: 8/21/24
Date of Infection Preventionist attendance at QAPI: 8/28/24
Correction date: 9/13/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN), Facilitator of the QAPI | Named in findings related to QAPI sign-in sheets and failure to wear PPE during tube feeding |
| Director of Nursing | Reported QAPI and QAA meetings are the same and involved in review of Enhanced Barrier Precautions |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 31, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification in compliance effective January 31, 2024.
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 4
Jan 2, 2024
Visit Reason
The inspection was conducted as the facility's Annual Recertification Survey from January 2, 2024 to January 4, 2024.
Findings
The facility failed to report injuries of unknown origin for one resident and failed to investigate alleged abuse thoroughly. Additionally, the facility did not accurately complete resident assessments and failed to follow physician's orders and sanitary practices for medication administration.
Complaint Details
The complaint investigation revealed that Resident #10 had a bruised eye of unknown origin that was not reported or properly investigated by the facility. The Director of Nursing failed to complete an Incident Report and did not obtain statements or conduct a thorough investigation. The bruise resolved by the time of the report.
Severity Breakdown
Level D: 3
Level E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to report injuries of unknown origin to the State Agency for Resident #10. | Level D |
| Facility failed to investigate injuries of unknown origin for Resident #10. | Level D |
| Facility failed to accurately complete resident assessments for Resident #42. | Level D |
| Facility failed to follow physician's orders and sanitary medication administration practices for multiple residents. | Level E |
Report Facts
Census: 46
Residents reviewed: 12
Medication administrations observed: 5
Medication orders: 7
Medication orders: 81
Medication orders: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurses Aid (CNA) | Reported noticing Resident #10's bruised eye. |
| Staff B | Licensed Practical Nurse (LPN) | Reported about the bruise on Resident #10 and assumed injury cause. |
| Staff C | Certified Nurses Aid (CNA) | Failed to see bruise on Resident #10 on a specific day. |
| Staff D | Certified Nurses Aid (CNA) | Reported bruise to Staff B. |
| Staff E | Certified Nurses Aid (CNA) | Reported first seeing the bruise on Resident #10. |
| Director of Nursing (DON) | Director of Nursing | Failed to see Incident Report for Resident #10's bruise and did not complete investigation. |
| Staff F | MDS Coordinator | Completed Care Plan and MDS documentation; revealed need for correction. |
| Staff B | Registered Nurse (RN) | Observed medication administration violations. |
| Staff A | Licensed Practical Nurse (LPN) | Administered insulin to Resident #29. |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 11, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Clarence Nursing Home, indicating acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was certified in compliance effective August 11, 2022, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies are detailed in the document.
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 2
Jul 11, 2022
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of a Facility Self-Reported Incident #101433-I from July 5, 2022 to July 11, 2022.
Findings
The facility failed to update residents' care plans timely and maintain safe food storage practices. Specific deficiencies included outdated care plans for multiple residents and improper labeling and storage of food items in the kitchen.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to update comprehensive care plans for residents #1, #14, #18, #24, #38, and #95 in a timely manner. | SS=E |
| Failure to maintain safe food storage in the kitchen, including leftover food not properly dated and an uncovered glass of ice water. | SS=E |
Report Facts
Residents reviewed: 12
Census: 43
Audit duration: 8
Audit duration: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Reported MDS Coordinator responsibilities and care plan update expectations during interview | |
| MDS Coordinator | Responsible for updating care plans and completing Minimum Data Set (MDS) | |
| Food Services Supervisor (FSS) | Provided statements regarding food storage policies and practices | |
| Dietary Food Supervisor | Disposed of outdated food items and provided food storage information | |
| Staff E, Cook | Provided information on food labeling and storage practices | |
| Staff F, Dietary Aide | Described labeling procedures for drinks placed in kitchen refrigerator |
Inspection Report
Renewal
Census: 46
Deficiencies: 1
Jul 22, 2021
Visit Reason
The inspection visit was conducted as a Recertification Survey completed between 7/19-7/22/2021 to assess compliance with federal regulations.
Findings
The facility failed to meet professional standards during medication administration and storage, specifically pre-setting medications in medication carts, which was against facility policy. The Director of Nursing expected nurses to administer medications directly without pre-setting.
Deficiencies (1)
| Description |
|---|
| Facility failed to follow professional standards during medication administration and storage review for 1 out of 1 medication carts reviewed, including pre-popped medications and medication cups holding white powder. |
Report Facts
Census: 46
Date of survey completion: Jul 22, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported medication setup status during interview |
| Director of Nursing | Director of Nursing (DON) | Reported expectations for medication administration and storage |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Jan 25, 2021
Visit Reason
The inspection was conducted to investigate self-reported incidents #95163 and #95180 involving resident elopement and accident hazards at Clarence Nursing Home from 1/14/21 through 1/25/21.
Findings
The facility failed to ensure the resident environment was free of accident hazards, specifically failing to identify a resident's window as a potential exit leading to elopement. Multiple interventions were implemented including window alarms and supervision measures. The resident had a history of exit-seeking behavior and elopement attempts, and the facility had not adequately prevented these incidents.
Complaint Details
The investigation was triggered by self-reported incidents #95163 and #95180. Both incidents were substantiated as the facility failed to prevent resident elopement through an unsecured window.
Deficiencies (1)
| Description |
|---|
| Facility failed to identify resident's window as a potential exit leading to elopement and did not ensure the environment was free of accident hazards. |
Report Facts
Census: 41
Incident dates: 12
Window alarm installation date: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Reported resident's history of elopement and interventions |
| Staff B | Registered Nurse (RN) | Reported resident's elopement attempts and interventions |
| Staff C | Certified Nurse Aide (CNA) | Reported resident's elopement attempts and observations |
| Staff D | Certified Nurse Aide (CNA) | Reported resident's elopement attempts and interventions |
| Staff E | Certified Nurse Aide (CNA) | Reported resident's elopement attempts and observations |
| Staff F | Registered Nurse (RN) | Reported resident's history of elopement and family decisions |
| Director of Nursing (DON) | Director of Nursing | Reported changes in resident behavior and facility policies after elopement |
Inspection Report
Routine
Census: 41
Deficiencies: 0
Dec 30, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 44
Deficiencies: 1
Oct 28, 2020
Visit Reason
A Focused COVID-19 Infection Control Survey was conducted from 10/19/20 through 10/28/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found not in compliance with infection prevention and control requirements, including failure to follow CDC Infection Control Guidelines for COVID-19, resulting in 32 of 44 residents testing positive for COVID-19. Deficiencies were noted in screening, staff symptom monitoring, and infection control policies.
Severity Breakdown
F880 SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections. | F880 SS=F |
Report Facts
Total residents: 44
Residents positive for COVID-19: 32
Residents positive for COVID-19: 44
Residents positive for COVID-19: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Named in findings related to symptom reporting and screening failures |
| Staff B | Certified Nurse Aide (CNA) | Named in findings related to symptom reporting and screening failures |
| Jason Tjaden | CEO | Named as Board Representative and signed the document |
Inspection Report
Abbreviated Survey
Census: 44
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/16/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 44
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