A list of the most recent deficiencies for Clarence Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-05-27 | 2021-09-02 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-05-27 | 2021-09-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-05-27 | 2021-09-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-05-27 | 2021-09-02 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-05-27 | 2021-09-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-27 | 2021-09-02 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-05-27 | 2021-08-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-27 | 2021-08-03 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-05-27 | 2021-08-03 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-05-27 | 2021-08-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-27 | 2021-08-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-27 | 2021-08-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-05-27 | 2021-08-03 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-07-01 | 2021-08-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-01 | 2021-08-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-01 | 2021-08-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-01 | 2021-08-03 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Establish methods for sharing information. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Use approved construction type or materials. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Meet other general requirements. | Fire Safety | 2021-05-27 | 2021-08-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-04-04 | 2019-05-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-04 | 2019-05-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-04 | 2019-05-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-04 | 2019-05-22 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-04-04 | 2019-05-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-04 | 2019-05-22 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-04-04 | 2019-05-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-04-04 | 2019-05-22 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-04-04 | 2019-05-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-04-04 | 2019-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-04 | 2019-05-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-04-04 | 2019-05-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-04-04 | 2019-05-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-04 | 2019-05-22 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-04-04 | 2019-05-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-06-05 | 2018-08-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-06-05 | 2018-08-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-06-05 | 2018-08-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-06-05 | 2018-07-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-06-05 | 2018-07-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-06-05 | 2018-07-20 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-06-05 | 2018-07-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-05 | 2018-07-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-05 | 2018-07-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-06-05 | 2018-07-20 | N |
