Clark Manor

In the surveyor’s words

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

• Actual harm, isolatedF600Mar 27, 2024

  Based on interview and record review, the facility failed to prevent and protect residents from resident-to-resident physical abuse. This failure affects two (R1, R5) residents out of seven residents reviewed for abuse. As a result of this failure, R2 hit R1 in the face with a shoe on 02/28/2024 resulting in R1 sustaining a facial laceration, being sent to the hospital, and requiring four sutures; facility failed to protect R5 from physical abuse by R4. Findings includes: Facility reported incident/FRI dated 02/28/2024 documents that the facility reported an altercation between R1 and R2. FRI documents that R1 reported R2 hit R1 with a shoe. […]

• Actual harm, isolatedF600May 24, 2023

  Based on interviews, and record reviews the facility failed to ensure R1 is free from abuse in a sample of 3 residents reviewed for abuse. This failure resulted in R1 acquiring two dental (teeth) fractures and a cut on the nose that required hospital evaluation and 7 stitches between upper lips and nostrils. Findings include: Facility's incident reportable regarding R1 documents in part: On 4/26/23, staff observed R1 with some blood on her linens. Nurse immediately assessed R1 and noted that she had a cut on her nose. The third roommate alleged both roommates, R1and R2 bumped into each other, and R1 lost her balance and fell . Both residents were immediately separated by staff. R1 was sent to the hospital for medical assessment via 911. […]

• Actual harm, isolatedF689Jan 8, 2023

  Based on interviews, and records review, the facility failed to provide adequate fall prevention and monitoring for one resident (R2) of 3 residents reviewed for falls. This failure resulted in R2 sustaining a fall with injuries requiring R2 to receive stitches on the forehead and R2 sustaining a fracture on the right hand. Findings include: Facility reported incident report dated 12/25/2022 documents: on 12/25/2022 at 02:35am, floor nurse heard a noise coming from the east shower room. Staff went to investigate and observed R2 on the shower room floor, face down. R2 was observed to have a laceration to the forehead with minimal amount of bleeding and a small cut to the left upper lip area. R2 stated I fell and hit my head. […]

• Actual harm, isolatedF600Aug 3, 2022

  Based on interview and record review the facility failed to protect a resident rights to be free from physical abuse for 1 (R1) of 6 (R2, R3, R4, R5, R6) residents reviewed for abuse. This failure resulted in R1 sustaining a laceration to the left arm and left leg, requiring hospital evaluation, 7 sutures to the left lower leg, 2 sutures to the left arm and a subsequent hospitalization due to an infection to the left leg laceration. Findings Include: R2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Feb 7, 2022

  Based on interview and record review, the facility failed to follow facility protocol and monitor a resident every two hours. This failure affected one resident (R1) of three residents reviewed for supervision. The facility failure resulted in R1 observed in R1's room hanging, unresponsive and pronounced dead. Findings include: R1's Admission Record documents, in part, that R1 was a [AGE] year-old resident with a diagnosis of [CONDITION(S)] Disorder [CONDITION(S)] Type and an admitted to the facility of [DATE] from a hospital stay of [DATE] to [DATE]. Facility Reported Incident of [DATE] at 6:45 am documents in part R1 was observed hanging and unresponsive by the assigned CNA (V20) on duty. Code blue initiated, R1 was eased down, CPR (Cardiopulmonary Resuscitation) started, 911 was called. […]