Clovernook Health Care and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Clovernook Health Care and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689May 28, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, observation, staff interviews, interview with the Medical Director (MD), review of hospital records, review of facility investigation, review of witness statements, review of personnel records, review of Hoyer Lift Manufacturer Guidelines, and review of facility policy, the facility failed to ensure a resident was safely transferred by a Hoyer mechanical lift. This resulted in Actual Harm on 12/19/23 when Resident #15 was being transferred from the wheelchair to the bed with the use of a mechanical lift by former State tested Nursing Assistant (STNA) #30 and STNA #30 hit the resident's right leg on the mechanical lift support bar. […]

• No harm, potential for more than minimal, widespreadF812Apr 14, 2026

  Based on observation, staff interview, and review of the facility policy, the facility failed to store food in a safe and sanitary manner. This had the potential to affect all 115 facility-identified residents who received food from the kitchen. The facility census was 119 residents.Findings include:1.Observation on 04/06/26 at 8:25 A.M. of the kitchen with Diet Manager (DM) #600 revealed following concerns: - The walk-in refrigerator contained the following items: two pans of uncovered prepared foods with no date or label, four wrapped sandwiches undated, a bag of boiled eggs with no open date, an opened container of cottage cheese with a use by date of 04/01/26, a bag of opened undated cheese, a bag of opened and undated lettuce. […]

• No harm, potential for more than minimal, widespreadF850Apr 14, 2026

  Based on review of personnel records and staff interview, the facility failed to employ a full-time qualified Licensed Social Worker (LSW). This had the potential to affect all of the residents residing in the facility. The facility census was 119 residents.Findings include:Review of the employee file for Social Service Worker (SSW) #175 revealed a hire date of 02/26/25 as a Certified Nursing Assistant (CNA). On 10/27/25 the facility promoted the CNA to her current position as SSW. Further review of SSW #175's employee file revealed the SSW was not a licensed social worker. Interview on 04/08/2026 at 3:23 P.M, with the Administrator confirmed the facility was licensed for 126 Medicare/Medicaid beds and was required to have a full-time qualified LSW working at the facility. […]

• No harm, potential for more than minimal, widespreadF880Apr 14, 2026

  Based on observation, staff interview, and review of the facility policy, the facility failed to ensure nursing staff followed proper hand hygiene protocols. This had the potential to affect all of the residents residing in the facility. Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to implement enhanced barrier precautions for one (Resident #23) of 40 residents with orders for EBP. The facility census was 119 residents.Findings include: 1.Observation on 04/06/26 at 8:15 A.M. revealed Unit Manager (UM) #400 had long multicolored artificial fingers nails with raised decorations on each of her fingers which extended beyond the tips of her fingernails. Interview on 04/06/26 at 8:15 A.M. […]

• No harm, potential for more than minimal, widespreadF924Apr 14, 2026

  Based on observation and staff interview, the facility failed ensure corridors were equipped with handrails on each side. This could potentially affect all 119 residents residing in the facility. The facility census was 119. Findings include: Observation on 04/08/26 at approximately 9:59 A.M. noted that emergency electrical equipment, including transfer switches, manual disconnect switches, and emergency electrical panels, in the egress corridor was not guarded against accidental contact. The facility recently installed a new generator with two transfer switches, manual override switches, and electrical panels in the egress corridor on the first floor that leads to the resident outdoor picnic and smoking areas. […]