Clara City Care Center

In the surveyor’s words

From the most serious findings on record at Clara City Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 23, 2025

  Based on interview and document review, the facility failed to ensure doors were secured and failed to implement individualized interventions to prevent/reduce the risk of elopement for 1 of 3 residents (R1) who had a history of exit seeking behaviors. This resulted in an immediate jeopardy (IJ) when R1 eloped from the facility through two unsecured doors and the wander guard alarm did not work. R1 was later found and returned to the facility by a passerby. The IJ began on 10/13/25, when staff failed to identify doors were not secured and failed to develop and implement appropriate interventions when R1 displayed exit seeking behaviors and left the building unwitnessed. The director of nursing (DON) was notified of the IJ on 10/22/25 at 3:05 p.m. […]

• Immediate jeopardy, isolatedF689Jul 16, 2025

  Based on interview, observation and document review, the facility failed to ensure safe use of a mechanical lift per manufacturer's recommendations to transfer 1 of 11 residents (R1), who required a mechanical lift for transfers. This resulted in an immediate jeopardy (IJ) when R1 fell from a full body mechanical lift causing R1 to suffer fractures to her cervical spine (C1 and C6), nasal cavity, and left femur as well as lacerations to facial area requiring hospital admission. In addition, the facility failed to ensure a system for completed comprehensive assessments for sling size and/or care plan development for 9 of 11 residents (R1, R2, R3, R5, R6, R8, R9, R10, R11) reviewed who required mechanical lifts. […]

• Actual harm, isolatedF689Dec 4, 2025

  Based on interview and record review the facility failed to adequately supervise a resident to reduce the risk of falls for 1 of 3 residents (R1) reviewed for accidents and supervision. R1 had a chair alarm that would sound when R1 would stand. The chair alarm prompted staff to respond to R1 after standing. R1 was found on her bathroom floor, transferred to the hospital with a left hip fracture.Findings include: According to the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Rev. 229, Issued: 04/25/25 supervision is an intervention and a means of mitigating accident risk. Facilities are obligated to provide adequate supervision to prevent accidents. […]

• No harm, potential for more than minimal, widespreadF812Apr 1, 2026

  Based on observation, interview and document review, the facility failed to ensure refrigerated food items were properly labeled, dated, and closed after the packaging was opened to prevent cross contamination which had the potential to affect all 28 residents currently residing in the facility. In addition, the facility failed to ensure refrigerated food items were disposed of after the expiration date or opened per facility policy. Findings Include:During the initial tour of the main kitchen on 3/30/26 at 12:36 p.m., with the dietary manager (DM)-A, the following areas of concern were identified and confirmed by DM-A:Upright refrigerator:-small disposable covered container of cake dated 3/5/26.-plastic half bag of salami slices, opened, undated.Walk In refrigerator:-opened gallon plastic… […]

• No harm, potential for more than minimal, widespreadF868Mar 6, 2024

  Based on document review and interview, the facility failed to ensure the required members and/or their designee attended the quarterly meetings for 3 of 4 quarterly Quality Assurance Performance Improvement (QAPI) meetings. Findings include: Review of the quarter 1 QAPI meeting attendance form for 1/10/23, identified the facility administrator was not present at the meeting. There was no documentation related to his absence and if there had been someone designated in his absence. Review of the quarter 3 QAPI meeting attendance form for 7/11/23, identified the facility infection preventionist was not present at the meeting. There was no documentation related to her absence and if there had been someone designated in her absence. […]