Clark Retirement Community

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 30, 2025

  This citation pertains to intake: 1293524 Based on record review and interview, the facility failed to ensure a safe transfer and implement facility policy to prevent falls in 1 of 4 residents (Resident #2) reviewed for fall prevention, resulting in a fall during a lift transfer resulting in a right fractured humorous for Resident #2, which had impacted the resident's functional status and quality of life with the potential for further injury and falls due to unsafe transfers. […]

• Actual harm, isolatedF689Mar 21, 2024

  This citation pertains to Intake #MI00143296. Based on interview and record review, the facility failed to implement fall interventions (utilize a bedside impact/fall mat) for 1 resident (Resident #100) of 4 residents reviewed for accidents and hazards, resulting in Resident #100 falling out of bed sustaining a soft tissue laceration over the midline frontal scalp, non-displaced facial fractures, and mild displaced angular fracture of the left humeral shoulder and the potential for further accidents and hazards to occur for residents at risk for falls. […]

• No harm, potential for more than minimal, widespreadF727Jul 30, 2025

  Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for 8 consecutive hours per day, 7 days per week, resulting in the potential for unmet care needs, resident change of condition to not be properly assessed and negative clinical outcomes. This deficient practice has the potential to impact all 29 residents currently residing in the facility. Findings include:Review of Nursing Schedules for 1/1-3/31/25 revealed the facility did not provide RN coverage for 8 consecutive hours per day, 7 days per week during 5 of 14 weekends included in this timeframe.Review of Nursing Schedules with a reference date of 5/1-7/27/25 revealed the facility did not provide RN coverage for 8 consecutive hours per day during any of the 13 weekends included in this… […]

• No harm, potential for more than minimal, widespreadF812Jul 30, 2025

  Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings include: On 07/28/25 at 9:40 AM, Observation of the clean utensil storage area found a mechanical scoop stored with stuck on food debris. Further observation found that the bins containing whisks and spoons were found with an increased accumulation of crumb debris. When asked how often this area gets cleaned, Dining Services Director (DSD) W stated they should get done every Tuesday. On 07/28/25 at 10:05 AM, An interview with DSD W found that the tabletop mixer and the slicer get used often. […]

• No harm, potential for more than minimal, widespreadF882Jul 30, 2025

  Based on interview and record review, the facility failed to ensure that a qualified Infection Preventionist worked at least part-time at the facility, was provided sufficient time to perform the Infection Preventionist role, and to properly assess, implement, and manage the Infection Prevention and Control Program.Findings include:During an interview and record review on 7/29/25 at 10:00 AM, Infection Control Preventionist/Director of Nursing/Unit Manager (ICP/DON) B stated, I am the DON, ICP, and UM not only for the LTC side of the facility but also for AL (Assisted Living). I do MDS (Minimum Data Set) part-time as well. This all takes up a lot of time. […]