Clinton Healthcare LLC - SNF

Inspectors wroteBased on interview, record review and policy review the facility failed to have an Advance Directive readily available for staff usage if needed for one (1) of twenty-three (23) resident Advance Directives reviewed. Resident #83Findings include:A record review of the facility policy, Residents Rights Regarding Treatments and Advance Directive, no date, revealed, Policy: It is the resident's right to formulate an Advance Directive, and to accept to refuse or accept medical or surgical treatment. Procedure. 1. On admission, the facility will determine if the resident has formulated an Advance Directive .On 11/18/25 at 12:25 PM in an interview with License Practical Nurse #2 (LPN) who works in Medical Records confirmed that the advance directive was not in the paper chart. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to implement its abuse-prevention policy by not completing a written investigation when staff were made aware of suspected physical abuse for one (1) of 21 sampled residents (Resident #106).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one (1) of twenty-three (23) residents reviewed for assessment accuracy (Resident #40). This is evidenced by the facility incorrectly coding the resident as receiving anticoagulant therapy on two consecutive MDS submissions.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure oxygen-use cautionary signage was posted on or near the resident's door for one (1) of one (1) resident reviewed for respiratory care, Resident #78.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to follow infection control guidelines when a Certified Nursing Assistant (CNA) provided catheter care while wearing false fingernails that interfered with glove use and effective hand hygiene for one (1) of four (4) care observations, Resident #5.

Inspectors wroteBased on observations, interviews, record reviews and policy reviews, the facility failed to provide wound care in a manner to prevent the possibility of wound infection for two (2) of (2) wound care observations. Resident #1 and Resident #4 Findings Include: A record review of the facility's policy titled Wound Care dated 1/2015 revealed Policy: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Procedure: .After cleaning the wound as ordered, clean the tissue around the wound . On 4/10/25 at 11:12 AM during an observation of wound care for Resident #1 by Licensed Practical Nurse (LPN) # 1/Wound Care Nurse and assisted by Certified Nursing Assistant (CNA) #1 revealed LPN #1 cleaned the stage IV pressure injury wound bed from the outer edge toward the inner aspect in a circular motion. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy reviews, the facility failed to provide wound care and incontinent care in a manner to prevent the possibility of spreading infection by not wearing a gown for Enhanced Barrier Precautions (EBP) during wound care and failing to perform proper hand hygiene during incontinent care. This deficient practice was observed for two (2) of two (2) residents reviewed for infection control practices (Resident #1 and Resident #4).

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to reasonable accommodation of needs regarding a call light for one (1) of 24 sampled residents. Resident #39. Findings Include: Review of the facility's booklet, A Matter of Rights: A Guide to Your Rights and Responsibilities as a Resident that is provided to residents upon admission, page four (4) revealed, Dignity and Respect . This includes the right .to expect care and a residential setting that .promotes your quality of life .reflects your individual needs and preferences . During an observation and interview, Resident #39 was observed lying on her side in bed on 6/11/24, at 9:10 AM, with the call light attached to her blanket just below her hands. The resident mentioned she frequently finds it difficult to get staff members to check on her. [...]

Inspectors wroteBased on observation, interviews, record review, and the facility policy review, the facility failed to ensure a residents' right to privacy by posting a sign regarding resident's care in view, above the bed for one (1) of 24 sampled residents. Resident #28.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure an enteral feeding pump was operated by licensed staff for two (2) of three (3) residents observed with Percutaneous Endoscopic Gastrostomy (PEG) tube feedings. (Resident #47 and Resident #93) Findings Include: Review of the facility's policy, Enteral Pump Alarm revised 1/2015, revealed It is the policy of this facility for enteral pumps to only be turned off and on by a licensed nurse. This procedure should never be delegated to assistive personnel .Procedure .Only licensed nurses will control the operations of the enteral feeding pump . Resident #47 During an observation, on 6/11/24 at 2:11 PM, Certified Nurse Aide (CNA) #1 entered Resident #47's room to provide incontinent care. CNA #1 turned off the resident's enteral feeding pump. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a resident was free from unnecessary medication by continuing an as needed (PRN) psychotropic medication past a 14-day duration for one (1) of six (6) residents sampled for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff treated residents who had visual impairment with dignity and respect, as evidenced by failure to knock on doors and identify themselves prior to entry for two (2) of six (6) residents reviewed. Resident #1 and Resident #2. Findings Include: Review of the facility's policy titled, Residents' Rights, dated 1/24/2022, revealed, .Residents' rights, policies, and procedures shall insure that each resident admitted to the center: .9. Is treated with consideration, respect, and full recognition of his dignity and individuality, including privacy in treatment and in care for his personal needs . Resident #2 On 12/11/23 at 4:20 PM, during an interview with Resident #2, the resident reported that she had been diagnosed with Legal Blindness. [...]

Inspectors wroteBased on observation, interview, record review, and facility review the facility failed to implement care plan interventions for a resident who had visual impairment for one (1) of six (6) residents reviewed. Resident #2 Findings Include: Record review of the facility policy titled, Following the Care Plan Policy, dated 3/21/22, revealed, Policy: It is the policy of this facility to follow a written and approved care plan for each resident. All employees will be trained upon hire and be required to follow the care plan . Procedure . 3. All employees will follow the written care plan that is developed in order to assure the residents needs are met. Record review of the Care Plan for Resident #2 revealed Focus I am legally blind, Dx (diagnosis) of Legal Blindness, Diabetes, ESRD (End Stage Renal Disease) .Date Initiated: [...]

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to resolve repeated dietary concerns reported during three (3) of the six (6) Resident Council meeting minutes reviewed.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to provide a financial record or quarterly statements to the resident or his/her representative, as voiced in Resident Council for four (4) of 12 residents interviewed. Residents #16, #19, #32, and #45. Findings Include: Review of the facility's policy, Quarterly Accounting of Resident Funds (undated) reveals, Our facility provides each resident who has funds managed by the facility on his/her behalf with a quarterly accounting of such funds . 1. An individual quarterly accounting of funds managed by the facility will be provided to each resident with personal funds entrusted to the facility. Residents may also receive an accounting of such funds upon making such request known to the Business Office. 2. Separate quarterly statements will be prepared by the Business Office and each record will include: a. [...]

Inspectors wroteBased on interviews, record review, and facility policy review the facility failed to provide written notification to the Resident and the Resident's Representative (RR) of an emergency transfer to the hospital for three (3) of three (3) residents reviewed for hospitalizations. (Resident #31, Resident #68, and Resident #88) Findings Include: A record review of the facility's policy Transfers and Documentation with a revised date of 11/2017, revealed . E. Documentation . The documentation for all discharges and transfers must include, as a minimum, and as they apply: 1. The reason (s) for the discharge or transfer. 2. That an appropriate notice was provided to the resident and/or resident representative. [...]

Inspectors wroteBased on staff interview, facility policy review and record review the facility failed to provide to the Resident or Resident Representative (RR) written notice at the time of transfer of the duration of the Bed Hold Policy for three (3) of three (3) residents reviewed for transfers and discharges. Resident #31, Resident #68, and Resident #88

Inspectors wroteBased on observation, staff interviews, record reviews, and facility policy review, the facility failed to develop a comprehensive care plan for a resident who was at risk of falls for one (1) of 22 residents reviewed. Resident #304 Finding Include: Review of the facility's policy, Care Plans-Comprehensive, dated 10/2016, revealed an individualized (person-centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . Record Review of Resident #304's admission Record, reveals the resident was admitted to the facility on [DATE] with diagnoses that included Cognitive Communication Deficit, Essential Hypertension, Ataxia, Lack of Coordination, and Muscle Weakness. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide services to meet professional standards of practice regarding the administration of medications to dialysis residents per physician orders for one (1) of two (2) dialysis residents reviewed. Resident #47 Findings Include: Review of the facility's policy Administration of Eye Drops or Ointments, updated 4/20/22, revealed Eye medications are administered as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye conditions . Review of Resident # 47's admission Record revealed admission of 01/10/2018 with medical diagnoses that included End Stage Renal Disease, Dependence on Renal Dialysis, Diabetes Mellitus Type II, and Unspecified Glaucoma. [...]

Inspectors wroteBased on interviews and facility policy review, the facility failed to provide mail delivery on Saturday to residents. This deficient practice has the potential to effect 103 of 103 residents residing at the facility.