Clinton House Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Feb 9, 2022

  Based on interview and record review, the facility failed to ensure an anticoagulant medication was transcribed on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident F). This resulted in Resident F not receiving the medication from admission on 08/25/2021 through discharge to the emergency roiagnom on [DATE], experiencing a Stroke. The Immediate Jeopardy began on 08/25/2021, when Resident F received one dose of [MEDICATION(S)] (an anticoagulation) at his previous facility. He was admitted to this facility, on 8/25/21, with orders for [MEDICATION(S)]. [MEDICATION(S)] was not ordered for the resident. The resident did not receive the medication from 8/25/21 through 10/11/21. […]

• Actual harm, isolatedF689Aug 31, 2022

  Based on interview, observation and record review, the facility failed to ensure the emergency brake was engaged before assisting a resident off the facility bus (Resident 63) and to ensure a resident was secured in the wheelchair during transport in the facility bus (Resident 43) for 2 or 5 residents reviewed for falls. Resident 63 sustained a hematoma to her left knee and a fractured pelvis. Findings include: 1. During an interview, on 08/26/22 at 9:17 a.m., Resident 63 indicated she fell while being transported in the facility bus to the hospital for a scheduled echocardiogram (an ultrasound of the heart). CNA 11 was driving the bus, pulled up to the emergency room door and then stopped the bus. The resident stood up from her seat and walked to the lift at the back of the bus. […]

• No harm, potential for more than minimal, widespreadF812Sep 1, 2023

  Based on observation, interview and record review, the facility failed to ensure the refrigerator did not contain employee drinks, the dishwasher was washing at the recommended temperature and the sanitizing solution bucket levels were in range. This deficient practice had the potential to affect 77 of 77 residents who received food from the kitchen. Findings include: During the kitchen observation, on 8/27/23 at 11:06 p.m., with the Dietary Manager (DM) the following were observed: a. The reach-in refrigerator contained a medium size fast-food cup with a brown drink and a straw. b. The red sanitizer bucket was tested twice. The DM placed a test strip into the bucket and the strip did not change colors. […]

• No harm, potential for more than minimal, patternF755Sep 1, 2023

  Based on observation, interview and record review, the facility failed to ensure the reconciliation of controlled drugs in 3 of 3 medication carts reviewed for controlled drugs and to maintain insulin medication integrity for 2 of 2 residents reviewed for insulin medication distribution. (Residents 15 and 4) Findings include: 1a. During the record review of controlled drug records, on 8/30/2023 at 3:01 p.m., the Medication Cart 200, Shift Change Controlled Substance Inventory Count Sheet (narcotic count record- reconciliation) was incomplete for the Month of August 1 through 27, 2023. The narcotic count record -reconciliation sign in and sign out documentation record for August 1 through 27, 2023 was missing 48 of 124 entries. b. […]

• No harm, potential for more than minimal, patternF921Aug 31, 2022

  Based on observation and interview, the facility failed to ensure water temperatures were at a comfortable and safe level for 2 of 6 bathrooms reviewed (Room 602 and 508) and bathroom doors were in good condition for 9 of 9 rooms observed on the memory care unit. (Rooms 706, 707, 708, 709, 710, 711, 712, 713 and 715) Findings include: 1. During an interview, on 8/25/22 at 1:37 p.m., Resident 1 indicated the water in the bathroom was cold. During a facility tour, with the Maintenance Director, on 8/29/22 at 2:26 p.m., the following were observed: a. The bathroom water temperature in room 602 was 98 degrees. b. The bathroom water temperature in room 508 was 133 degrees. During an interview, on 8/29/22 at 2:26 p.m., the Maintenance Director indicated the facility had 2 hot water tanks. […]