Clairidge House

In the surveyor’s words

From the most serious findings on record at Clairidge House, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580May 2, 2022

  Based on record review and interview, the facility did not ensure that staff promptly consulted with a physician when residents experienced significant changes of condition. This was observed with 3 (R36, R40 and R32) of 12 residents reviewed. * R36 is dependent on staff for fluid and meal intakes. R36 also was on a scheduled diuretic, 20mg of [MEDICATION(S)] each day for [CONDITION(S)]. On 11/10/21, R36 experienced a change in condition. R36 ate only 25% at each meal and took in approximately 120 cc fluid at each meal. Charting on the 24- hour board indicates she was somewhat lethargic. […]

• Immediate jeopardy, isolatedF692May 2, 2022

  Based on observation, record review and interviews, the facility did not ensure residents' fluid intakes were assessed or monitored. This was observed with 3 (R36, R33 and R31) of 3 residents reviewed for hydration concerns. *R36 is dependent on staff for meal and fluid intakes. R36 was sent out to the hospital via 911 on 11/15/21 for severe dehydration and required aggressive fluid resuscitation. On 11/10/21, R36 started experiencing a change in condition becoming more lethargic with decreased intake. The facility did not involve the dietitian for reassessment of R36's food and fluid intake in order to develop an individualized care plan to ensure hydration. […]

• Actual harm, isolatedF686Mar 5, 2026

  Based on record review, interview and observations, the facility did not ensure residents received comprehensive assessments, interventions and treatment, to prevent and heal, pressure injuries. This was observed with 4 (R3, R9, R1 and R16) of 4 residents reviewed with pressure injury. *R3 was at high risk for a pressure injury, developed a facility acquired stage 3 pressure injury, that was not comprehensively assessed upon discovery. R3 did not have interventions revised to promote healing. This resulted in actual harm to R3. *R9 had facility acquired pressure injuries to the left upper posterior thigh area and left medial thigh. On 3/03/2026, Surveyor observed R9's wound treatment which was not completed per the order. […]

• Actual harm, isolatedF686May 2, 2022

  Based on observation, record review and interview, the facility did not ensure the prevention, and healing of pressure injuries. This was discovered in 2 (R33 and R2) of 3 residents reviewed with pressure injuries. * R33 developed a fissure above the sacrum on 3/24/21. There was no further assessment of this area until 4/22 and 4/29/21. On 5/13/21, the fissure became larger and the MD was contacted for new treatment. On 6/10/21 the assessment indicated slough in fissure. On 7/17/21, R33 was admitted to the hospital where it was noted upon admission, R33 had a stage 3 pressure injury on the sacrum. The facility had not identified the fissure as a stage 3 pressure injury. […]

• Actual harm, isolatedF689May 2, 2022

  Based on observation, interview, and record review, the facility did not ensure that 3 (R32, R38, R31) of Residents reviewed for accidents had adequate assistance devices and interventions in place to prevent accidents and that the environment was free of accident hazards. * R32 was assessed as being unsafe with smoking 8/25/21. On 4/10/22, R32 was outside smoking with a family member. R32 sustained a second or third degree burn to the left anterior knee. R32 stated he did not mean to burn himself. R32 was allowed t smoke without staff supervision. *On 5/8/21, R38 fell in his room sustaining a laceration that required 13 sutures. R38's interviews reveals prior to the fall he had informed maintenance about a piece of wood sticking out from bed footboard. […]