Clinton Therapy & Living Center

In the surveyor’s words

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

• Immediate jeopardy, patternF607Aug 30, 2023

  On 08/25/23, an IJ situation was determined to exist related to the facility's failure to implement their abuse policy to ensure: a. Allegations of abuse were fully investigated, b. Residents were protected during an investigation, c. Interventions were placed to prevent further allegations or abuse, and d. Allegations of abuse were reported in the time frame set by state and federal regulations. This resulted in Resident #21 to report to the surveyor, an event of an unidentified male in their room that had their hand in Resident #21's pants. Resident #21 recognized the male as another resident that currently resides in the facility. The resident record documented staff were aware of the situation on 07/29/23 at 2:31 a.m. […]

• Immediate jeopardy, patternF689Aug 30, 2023

  On [DATE] at 2:41 p.m., the OSDH confirmed the existence of an immediate jeopardy related to the facility failed to ensure supervision to prevent elopement for Resident #24 and Resident #8. Resident #24 was at risk to wander and was observed to leave the facility with no staff supervision. Resident #8 was observed to exit the automatic door at the front exit and sat on a bench. The ADON was asked why Resident #8 was outside. The ADON stated Resident #8 wanted to leave AMA, and the behavior is a daily occurrence for the resident wanting to leave. There was no care plan for Resident #8 to be at risk for elopement. The facility failed to implement interventions, and provide supervision to ensure Residents who were at risk for elopement did not leave the facility without supervision. […]

• Immediate jeopardy, isolatedF689Apr 18, 2025

  On 04/18/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to protect residents with exit seeking behaviors. Resident #1 wandered and had exit seeking behaviors, got out of the facility on 02/16/25 and again on 04/09/25. On 04/09/25 Resident #1 eloped and was located a half mile away from the facility on a four-lane busy road. Resident #1's care plan did not address interventions of exit seeking behaviors on 02/16/25 and was not updated until 04/09/25 with interventions. Based on observation, record review, and interview, the facility failed to provide supervision and interventions to prevent elopement for 1 (#1) of 3 sampled residents reviewed for wandering and elopement. […]

• Immediate jeopardy, isolatedF689Sep 17, 2024

  On 09/16/24 at 2:47 p.m., OSDH identified the presence of an immediate jeopardy related to the facility failed to provide supervision for Res #1 to prevent recurring elopements. Res #1 was admitted to the facility on [DATE]. Res #1 was identified by family to be an elopement risk at the time of admit. Res #1 was assessed to be at risk for elopement. A care plan was not initiated until 06/11/24 with referrals to locked units and a gero-psych unit. Res #1 was placed on one on one supervision with every 15 minute visual checks. On 07/09/24, Res #1 eloped from the building and was found several blocks from the facility. The care plan was not updated until 08/16/24. No new information was added to the care plan. […]

• No harm, potential for more than minimal, widespreadF835Aug 30, 2023

  Based on observation, record review, and interview, the facility failed to be administered effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial being of each resident. The Administrator failed to ensure: a. resident assessments were completed and submitted in the required time frame, b. each resident had a completed comprehensive care plan to accurately reflect the needs and services of each resident, c. a safe and secure environment was provided to prevent cognitively impaired residents to wander or elope from the building, d. […]