Clarkfield Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 4, 2022

  Based on interview and document review the facility failed to perform root cause analyses and identify appropriate interventions to prevent the falls for 2 of 2 residents (R10 and R119). Both residents' falls resulted in actual harm when R10 suffered a neck fracture and R119 suffered pelvic fractures as a result. Findings include: R10 Review of the 1/12/22 at 1:25 p.m., facility incident report identified nursing staff walked past R10's room and heard him hollering for help. R10 was found lying face down on the floor in front of wheelchair with his legs under the wheelchair with his body partially covering the top of the wheelchair foot pedals. R10's call light was attached to the front of his shirt. […]

• Actual harm, isolatedF689Mar 11, 2021

  Based on observation, interview and document review, the facility failed to ensure 2 of 3 residents (R1 and R2) were provided appropriate supervision and intervention to prevent falls. This resulted in harm for R2 was not properly supervised, fell , and required emergency services for a head injury requiring staples. Findings include Review of facility report submitted to the State Agency (SA) on 1/22/21 at 10:46 p.m., it was identified R2 sustained a fall resulting in a scalp laceration requiring staples. The report indicated nursing assistant (NA)-D had been in R2's room to assist R2 to stand with a walker from her wheelchair. […]

• No harm, potential for more than minimal, widespreadF880Apr 8, 2026

  Based on interview and document review, the facility failed to document the date when transmission-based precautions (TBP) were implemented for 2 of 3 residents (R2 and R27). Findings include: R2's comprehensive Minimum Data Set (MDS) assessment accepted on 3/18/26, identified his cognition was intact. R2 was dependent on staff for transfers and bathing, he required substantial/maximal assistance with dressing. Review of the facilities resident infection prevention surveillance logs identified R2 had a confirmed upper respiratory infection identified on 1/30/26. He was placed on droplet precautions on 1/31/26 through 2/6/26. […]

• No harm, potential for more than minimal, widespreadF867May 15, 2024

  Based on interview and document review, the facility failed to ensure data submitted to 1 of 1 QAPI committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 24 residents. Findings include: Review of undated, current Quality Improvement Incentive Payment (QIIP) tool identified a plan to monitor moderate to severe pain in the first 100 days. The goals were to assess resident pain levels for verbal and nonverbal residents, offer non-pharmacological interventions, such as topical medications with massage, and therapy exercises. […]

• No harm, potential for more than minimal, widespreadF944May 15, 2024

  Based on interview and document review, the facility failed to provide mandatory training on 1 of 1 facility specific Quality Assurance Performance Improvement (QAPI) Program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. This had the ability to affect all 24 residents. Findings include: Interview on 5/13/24 at 5:18 p.m., with activity director stated she would attend the QAPI meetings regularly along with the facility administration, board members and the city administrator. She stated she was not aware if employees could attend QAPI and had not seen employees attend QAPI. […]