Clarence Nursing Home

In the surveyor’s words

From the most serious findings on record at Clarence Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 25, 2021

  Based on observations, record review, family and staff interviews, the facility failed to identify the resident's window as a potential exit with which the resident eloped through for one of five residents reviewed for supervision (Resident #1). The facility reported a census of 41 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) Admission Assessment completed 12/25/21 documented the following Diagnoses: [REDACTED]. It also identified the resident as cognitively intact with a Brief Interview for Mental Status) score of 12 out of 15, required limited staff assistance with walking and personal hygiene. […]

• No harm, potential for more than minimal, patternF812Aug 27, 2026

  Based on observation, staff interview, and facility policy review, the facility failed to ensure staff performed proper hand hygiene and maintained infection control practices during meal preparation and beverage service. This affected 2 of 2 residents receiving pureed diets and meal tray service for 1 of 1 dining observation.Findings include:Observation of puree prep and meal service on 08/25/2026 revealed the following:On 08/25/2026 at 10:13 AM, Staff B, Dietary Manager, prepared pureed meals for 2 residents. During the prep of yams, Staff B performed hand hygiene and donned gloves to remove 3 yams from aluminum foil into the puree machine. […]

• No harm, potential for more than minimal, patternF868Aug 22, 2024

  Based on staff interviews, facility record review and facility policy review the facility failed to have the required Infection Preventionist (IP) at 2 of 2 Quality Assessment and Assurance/Quality Assurance and Performance Improvement (QAPI) meetings. The facility reported a census of 45 residents. Findings included: The QAPI sign-in sheet dated 3/21/24 and 6/6/24 failed to reflect the signature of the Infection Preventionist. The sign-in sheet reflected Staff A, Licensed Practical Nurse, Facilitator of the QAPI. The facility provided a QAPI Members list undated, that identified Staff A as the QAPI Coordinator and included the Infection Preventionist name which was not listed on the QAPI sign-in sheet as referenced above. […]

• No harm, potential for more than minimal, patternF658Jan 4, 2024

  Based on clinical record review, observations, staff interviews, and facility document review, the facility failed to follow Physician's Orders for insulin administration (Resident #29). The facility further failed to follow sanitary practice when staff placed medication directly into ungloved hands then into the residents' mouths (Resident #19, #25, #33, #36) for 5 of 5 medication administrations observed. Findings Include: 1. The Minimum Data Set (MDS), for Resident #29, dated 12/07/23, revealed a Brief Interview for Mental Status (BIMS), score of 11 out of 15, indicative of moderate cognitive impairment. Diagnoses included: Diabetes Mellitus, Type 2, with long-term and current use of insulin, and non-Alzheimer's dementia. […]

• No harm, potential for more than minimal, patternF657Jul 11, 2022

  Based on Minimum Data Set Assessment Tool review, Care Plan review and staff interviews, the facility failed to update residents' Care Plans for 6 of 12 residents reviewed (Residents #1, #14, #18, #24, #38 and #95). The facility reported a census of 43 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #1 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 15, independent with Activities of Daily Living (ADL's) and with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Care Plan revealed marked as overdue for review which had been due 6/30/22 and identified the resident with the following problems: a. At increased risk for respiratory complications such as COVID. b. Diabetic. c. […]