Clinton Manor Living Center

In the surveyor’s words

From the most serious findings on record at Clinton Manor Living Center, in the surveyor’s own words.

• Actual harm, isolatedF692Aug 11, 2023

  Based on observation, interview, and record review, the facility failed to assess and treat 1 of 4 residents (R22) in the sample of 23. This failure resulted in the resident sustaining a significant weight loss of over 24 lbs. (approx. 15%) in 2 months. Findings include: R22's Face sheet documents, an admitted [DATE]. Diagnosis includes: Fracture of Unspecified Part of Neck of Left Femur, Displaced Oblique Fracture of Shaft of Humorous Right Arm, Atherosclerotic Heart Disease, Chronic Kidney Disease. R22's Minimum Data Set, MDS, dated [DATE] documents, R22 has no cognitive impairments. MDS dated [DATE] documents, R22 had no issues with eating, drinking, or choking. […]

• No harm, potential for more than minimal, widespreadF812Aug 11, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare and distribute food in a manner that prevents foodborne illness. This has the potential to affect all 21 residents living in the facility. Findings include: On 08/08/23 at 11:20AM V5, Cook, was removing items from the standing refrigerator. One container was labeled mechanical ham and was dated 07/31/23. On 08/08/23 at 11:22AM in the walk-in refrigerator there was an opened bag of mozzarella cheese that was sealed with plastic wrap but was not dated. On 08/08/23 at 11:24AM in the walk-in freezer there was a plastic bag containing round slices of meat, each approximately two inches in diameter. The bag was dated 07/13 but was not labeled. […]

• No harm, potential for more than minimal, widespreadF880Aug 11, 2023

  Based on interview and record review the facility failed to adequately develop an ongoing infection control program that adequately collects data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practices in the facility. The facility staff also failed to utilize appropriate Personal Protective Equipment, (PPE), when entering a COVID-19 rooms. This has the potential to affect all 21 residents living in the facility. Findings Include: 1. The facility's Antibiotic Surveillance Tracking Form for the month of January documents, R6 was given Cipro for a Urinary Tract Infection, (UTI) from 1/23/23 through 1/30/23, and no culture was ordered. […]

• No harm, potential for more than minimal, patternF881Aug 11, 2023

  Based on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use in 4 of 4 residents (R6, R17, R15, and R176) reviewed for antibiotic stewardship in the sample of 23. Findings include: 1-The Facility's Antibiotic Surveillance Tracking Log for the month of January 2023 documents, No culture ordered for R6's urinary infection. […]

• No harm, potential for more than minimal, isolatedF689Dec 5, 2023

  Based on interview and record review, the facility failed to follow the manufacturer's recommendations by ensuring the sling for a mechanical lift was secure, prior to transfer, for 1 of 3 residents (R2) reviewed for incidents/accidents, in the sample of 5. Findings include: R2's Care Plan dated 4/20/23 documents R2 is transferred via a mechanical lift with the assistance of two staff. It further documents R2 is at risk for falls and the goal is for R2 to be free of falls. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired and requires extensive assistance from two staff members for transfers. On 11/30/2023 at approximately 11:45 AM, V10, Certified Nursing Assistant (CNA) stated, (V7, CNA) and I were transferring (R2) to bed after lunch. […]