Clement Manor Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF678May 21, 2026

  Based on interview and record review, the facility failed to ensure 1 (R59) of 1 sampled residents, received basic life support, including cardiopulmonary resuscitation (CPR), in a timely and effective manner. This deficient practice has the potential to affect 4 of 46 residents with full code status.*R59 was identified as a full code and staff did not immediately initiate CPR upon discovering R59 was pulseless and non-breathing.The facility's failure to provide basic life support for a resident with a full code status, created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on [DATE] at 11:36 AM. The immediate jeopardy was removed on [DATE]. […]

• Actual harm, isolatedF689May 21, 2026

  Based on observation, interview, and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 2 (R9 and R23) of 4 residents reviewed for falls. *R9 experienced eleven falls since admission to the facility and R9's Falls plan of care was not revised after the falls to address the root causes of the fall. As a result of a fall, R9 sustained a right clavicle fracture and a left patella fracture. *R23 had a fall on 1/24/2026. The facility could not provide evidence that a post fall investigation was completed. R23's care plan was not updated post fall. Findings include: The facility policy and procedure titled Incidents – Reporting of Resident dated 5/2024 documents: PROCEDURE: . 5. […]

• No harm, potential for more than minimal, widespreadF812May 21, 2026

  Based on observation, staff interview, and record review, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety. This practice had the potential to affect all 46 residents residing in the facility. *Equipment in the kitchen was not in clean, sanitary condition. Three prep stations had grease built-up on the front and back, legs of prep stations had dried food on them, crumbs in the crevices of the doors, splattered dried food on the front. The heater had red dried splattered food on it. The temp fryer had crumbs on the crevices on the back and the cords and plug ins are extremely caked with dried food and grease. The stove had dried food and grease on the front, crumbs in the crevices under the buttons. […]

• No harm, potential for more than minimal, widespreadF880May 21, 2026

  Based on interview and record review the facility did not ensure a thorough investigation into a Covid outbreak was conducted. This had the potential to affect all 46 residents.The facility had a Covid outbreak on 2/7/26. The line list documents by 2/7/26, three residents were diagnosed with Covid. The facility did not conduct and document an investigation into this outbreak.Findings include:Surveyor reviewed the facility's Covid outbreak that began on 2/7/26. The outbreak line list documents on 2/15/26, R61 developed respiratory symptoms and tested positive for Covid. On 2/16/26, R39 developed respiratory symptoms and tested positive for Covid. On 2/17/26, R40 developed respiratory symptoms and tested positive for Covid. […]

• No harm, potential for more than minimal, widespreadF812Apr 1, 2021

  Based on observation, record review, and interview the facility did not ensure that food was prepared, stored and served under sanitary conditions in the facility kitchen with the potential to affect 40 of 40 residents whom receive food from the main serving kitchen in the facility on general, mechanical soft and pureed diets. - Dining Services Assistant (DA)-H was observed preparing pureed meal without gloves and not washing hands. DA-H lack of handwashing and not wearing gloves potentially effected the resident's on pureed diets in the facility. - Dining Services Supervisor (DS)-F and DA-I were observed serving food with gloved hands instead of utensils and not washing hands. […]