Clinton Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Clinton Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Feb 10, 2025

  Based on interview and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to transcribe new admission orders correctly for one resident (Resident #1) resulting in staff administering two medications in excess of the ordered dosage amounts for five days. Once notified of the error, the staff did not document notification of the physician of the medication error to obtain further direction. The resident passed away on the day the medication error was discovered. The facility census was 74. The Administrator and the Corporate Nurse were notified on [DATE], at 4:10 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. […]

• Immediate jeopardy, isolatedF689Jul 7, 2021

  Based on interview and record review, the facility staff failed to ensure the safety of all residents when transport staff failed to properly secure one resident (Resident #1) in the transport van. This resulted in the resident suffering a fall causing a C-2 (the second bone down from the skull in the neck vertebrae) fracture. The facility census was 67. On 07/07/21 at 2:10 P.M., the administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 1/21/21. […]

• Actual harm, isolatedF600Aug 29, 2022

  Based on interview and record review, the facility failed to ensure all residents were free from abuse when a staff member (Certified Nurse Aide (CNA) A) acted in an abusive manor by cursing at, and making contact with the face of, one resident (Resident #1) resulting in the resident being too upset to talk about the event initially without crying. The facility census was 65. Record review of the facility policy, titled Abuse Prevention Program, dated September 2021, showed the following: -The facility will not tolerate verbal or physical abuse by employees; -Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. […]

• No harm, potential for more than minimal, widespreadF843Feb 10, 2025

  Based on record review and interview, the facility failed to ensure a written transfer agreement with a hospital was in effect to ensure residents timely admission to the hospital when medically appropriate and that information would be exchanged between providers. This has the potential to effect all the residents. The facility census was 74. Review showed the facility did not provide a policy pertaining to written transfer agreements with a hospital or a written transfer agreement with a community hospital. During interviews on 02/10/25, at 1:30 P.M. and 2:10 P.M., the Regional Director of Operations said he/she was not aware of the federal requirement for the facility to have a written transfer agreement with a hospital. […]

• No harm, potential for more than minimal, patternF561Mar 26, 2025

  1. Please refer to event ID YO6F12, exit date 03/26/25, for details. Based on observation, record review, and interview, the facility failed to promote and facilitate each residents right to self-determination when staff failed to honor four residents' (Resident #1, #2, #3, and #4) shower preferences. The facility census was 71. Review of the facility's policy titled Bath, Shower/Tub, dated February 2018, showed the following information: -The purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Document the date and time the shower/tub bath was performed; -Document the name and title of the individual who assisted the resident; -Document all assessment data obtained during the shower/tub… […]