Clara City Care Center

Based on observation, interview and document review, the facility failed to ensure refrigerated food items were properly labeled, dated, and closed after the packaging was opened to prevent cross contamination which had the potential to affect all 28 residents currently residing in the facility. In addition, the facility failed to ensure refrigerated food items were disposed of after the expiration date or opened per facility policy. Findings Include:During the initial tour of the main kitchen on 3/30/26 at 12:36 p.m., with the dietary manager (DM)-A, the following areas of concern were identified and confirmed by DM-A:Upright refrigerator:-small disposable covered container of cake dated 3/5/26.-plastic half bag of salami slices, opened, undated.Walk In refrigerator:-opened gallon plastic container of ranch dressing, undated, expiration date of 9/25/25. -opened container of thousand island dressing, undated, expiration date 3/21/26.During a follow up interview on 3/31/26 at 1:33 p.m., DM-A stated most items that were opened should be disposed of after seven days. DM-A confirmed her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on document review and interviews, the facility failed to develop and implement comprehensive care plans for 2 of 3 residents (R1, R2) reviewed for elopement. Findings include: R1 was admitted to the facility on [DATE]. R1's face sheet dated 10/22/25, indicated diagnoses of dementia, depression, and anxiety.R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had mild cognitive impairment and required staff assistance for activities of daily living with transfers and ambulation. R1 used a wheelchair for locomotion. R1's elopement risk assessment dated [DATE], identified at risk for elopement related to resident being independent in wheelchair locomotion, cognitive impairment and making statements that he was leaving. R1 was at risk for elopement. R1's care plan dated 9/26/25, identified an elopement problem. The care plan indicated R1 was a t risk for elopement related to making statement of leaving to go home. The goal was for R1 to not elope from the facility during the next 90 days. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure an environment that was free of accident hazards, related to hot water temperatures in 6 of 6 resident rooms ( R9, R11, R16, R28, R31, R32,) tested for safe water temperatures. This deficient practice had the potential to affect all 6 residents who used water from the water faucets. Findings include: On 2/24/25 at 11:00 a.m., during resident screening the water temperatures in R9, R11, R16, R28, R31, and R32's rooms felt very warm to the touch after running water for one minute. During an observation and interview on 2/24/25 at 11:28 a.m., maintenance director (MD) verified the water in R9, R11, R16, R28, R31 and R32's room felt too hot and used the facility digital thermometer to measure the water temperatures in resident rooms. Water temperatures were as follows: -R9's room [ROOM NUMBER] was 129 degrees F. -R11 room [ROOM NUMBER] was 129 degrees F. -R16 room [ROOM NUMBER] was 129 degrees F. -R28 room [ROOM NUMBER] was 129…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY R16 R16's significant change MDS dated [DATE], identified R16 had severe cognitive impairment with diagnoses which included, Alzheimer's disease, heart failure, and anxiety. Identified R16 required substantial/maximal assistance with shower/bathing and upper body dressing, and was dependent for lower body dressing and transfers. R16's care plan revised 2/18/25, identified R16 had ADL self care deficit and needed assistance to complete ADLs. R16 required EBP, related to: open draining wounds to right lower extremity and was at risk of developing a multi-drug resistant organism/infection. Interventions included apply personal protective equipment (PPE) prior to providing wound care. Remove before leaving R16's room. R16's care plan lacked EBP intervention to include use of PPE with all high contact resident care activities. R16's Referral Form signed 2/7/25, included order: -wound on right leg-cleanse wound with wound cleaner, apply collagen (wound gel to promote healing) to wound beds, apply non-adherent super…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure 1 of 3 residents (R1) were treated with dignity and respect. Findings include: Review of facility reported incident dated 5/14/24, indicated trained medication aide (TMA-C) was administering R1's morning medications one 5/11/24, when nursing assistant (NA-L) asked if R1 was ready for breakfast. TMA-C stated R1 was finishing her Miralax (a laxative) when NA-L lunged toward R1 from behind R1 and grabbed the cup out of R1's hand when R1 refused to give up the cup. R1 screamed very loudly Damn it stop and leave me alone and continued to hold the cup fiercely. NA-L was hanging on to the cup tightly and TMA-C was trying to get the cup away from both R1 and NA-L. NA-L stated R1 did not need the Miralax right before she attempted to take the cup away from R1. R1 was visibly shaking and upset. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, with diagnoses that included altered mental status,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on document review and interview, the facility failed to ensure the required members and/or their designee attended the quarterly meetings for 3 of 4 quarterly Quality Assurance Performance Improvement (QAPI) meetings. Findings include: Review of the quarter 1 QAPI meeting attendance form for 1/10/23, identified the facility administrator was not present at the meeting. There was no documentation related to his absence and if there had been someone designated in his absence. Review of the quarter 3 QAPI meeting attendance form for 7/11/23, identified the facility infection preventionist was not present at the meeting. There was no documentation related to her absence and if there had been someone designated in her absence. Review of the quarter 4 QAPI meeting attendance form for 10/24/23, identified the facility administrator was not present at the meeting. There was no documentation related to his absence and if there had been someone designated in his absence. Interview on 3/4/24 at 2:42 p.m., with the director of nursing confirmed that the administrator had not been present…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure alcoholic beverages were secure in 1 of 1 resident refrigerator located in the east dining room. This had the potential to affect 4 out of 20 residents with diagnoses of dementia and with known confusion that ate in the east dining room (R21, R24, R27, R30) Findings include: Observation on 3/4/24 at 11:46 a.m., of the east dining room refrigerator identified 3 cans of Michelob Ultra left in a 12 pack, 5 bottles of [NAME] light in refrigerator door, and 1 bottle of Michelob golden. The refrigerator was unsecured, and all residents had access to the refrigerator. Interview on 3/4/24 at 3:18 p.m., with activity director identified the facility typically held activities in the west dining room related to some sound issues. She reported that the activity department did utilize the resident refrigerator in the east dining room. She stated that the facility did have a monthly activity called the Ritz where she invited all the residents…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review, the facility failed to maintain and monitor their system for the the disposition and security of emergency medication kits (E-kit) that contained controlled and/or narcotic substances for 1 of 3 E-kits to immediately detect and reconcile to prevent potential drug diversion. Findings include: Observation and interview on 3/5/24 at 10:02 a.m., with licensed practical nurse (LPN)-A of the facility's large emergency kit (E-kit) located in the medication room inside the medication cupboard was an attached inventory record that identified controlled medication of Morphine oral solution 10 mg/0.5 ml, lorazepam for injection 2 mg/ml injection, hydrocodone/APAP (Norco) 5/325 mg, and lorazepam 0.5 mg tablet. The large E-kit had a plastic lock with the number 1249464. A small red emergency kit also located in medication room cupboard with an attached inventory record identified controlled medications of Hydrocodone/APAP (Norco) 5/325 mg tables quantity 6, morphine oral solution syringe 10 mg/0.5 ml quantity 6 syringes, oxycodone oral tablet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to offer and/or administer the most recent Centers for Disease Control (CDC) pneumococcal vaccine for 2 of 5 residents (R23 and R24) reviewed for immunizations. Furthermore, the facility failed to have a method or system to ensure the facility offer or provided any initial or updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.