Clark Rehabilitation and Skilled Nursing Center

In the surveyor’s words

From the most serious findings on record at Clark Rehabilitation and Skilled Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 14, 2023

  Based on record review, interview and observation, the facility failed to ensure residents' Weekly Skin Assessments were completed and accurate, interventions were implemented, and treatment and monitoring was completed to identify and prevent the development or worsening of a pressure ulcer resulting in an unstageable pressure ulcer worsening to a Stage IV pressure ulcer for 3 of 6 residents reviewed for pressure ulcers. (Residents 62, 47 and 56) . Findings include: 1. The clinical record for Resident 62 was reviewed on 3/8/23 at 11:55 a.m. […]

• Actual harm, isolatedF689Mar 14, 2023

  Based on observation, record review and interview, the facility failed to ensure appropriate intervention to prevent a fall for 1 of 3 residents reviewed for falls, which resulted in the resident having broken bones, bruising, and skin tears. (Resident 35) Findings include: The clinical record for Resident 35 was reviewed on 3/9/23 at 2:18 p.m. The diagnoses included, but were not limited to, a fall slipping, tripping, and stumbling; muscle weakness; stiffness of the left ankle; pain in the right knee; stiffness of the right hip and right ankle; idiopathic peripheral autonomic neuropathy; contracture of the left and right ankle; mechanical complication of the internal fixation device of the right femur for a displaced supracondylar fracture; abnormal posture; and the need for assistance… […]

• No harm, potential for more than minimal, patternF842Jan 22, 2026

  Based on interview and record review, the facility failed to ensure residents' (Residents B, C, D and E) medication administration records reflected medications administered for 4 of 4 residents reviewed for medical records. Findings include:1.The clinical record for Resident B was reviewed on 1/21/26 at 1:51 p.m. The resident's diagnoses included, but were not limited to, a history of a deep vein thrombosis (dangerous formation of a blood clot inside a vein or artery) and neuropathy (nerve damage or dysfunction). Review of the January 2026 medication administration record (MAR) indicated the resident was to receive the following medications:-Eliquis (blood thinner) 5 mg (milligrams) twice daily between 7:00 a.m. and 11:00 a.m. and again between 7:00 p.m. […]

• No harm, potential for more than minimal, patternF842Jul 1, 2025

  Based on interview and record review, the facility failed to ensure medication administration records accurately reflected the administration of controlled substances 4 of 4 residents reviewed for medical records. (Resident B, C, D and E) Findings include: 1. The clinical record for Resident B was reviewed on 6/30/25 at 10:45 a.m. The resident's diagnoses included, but were not limited to, diabetes, chronic pain and gastrointestinal stromal tumor of the rectum. The June 2025 medication administration (MAR) record indicated the resident was to receive Oxycodone 15 mg (milligrams) every 4 hours for pain at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. […]

• No harm, potential for more than minimal, patternF695Mar 14, 2023

  Based on observation, record review, and interview, the facility failed to ensure the oxygen concentrator filters were applied and maintained for 6 of 18 residents reviewed for respiratory care. (Residents 33, 35, 56, 170, 171, and 49). Findings include: 1. The clinical record for Resident 33 was reviewed on 3/9/23 at 12:55 p.m. The diagnoses included, but were not limited to, copd (chronic obstructive pulmonary disease) with acute exacerbation, malignant neoplasm of upper lobe, left bronchus or lung, emphysema, and anxiety disorder. The physician's order, dated 10/4/22, indicated staff were to change the resident's oxygen tubing and humidity, and clean the concentrator and filter once a day on Sunday. […]