Clinton House Rehabilitation and Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received scheduled showers for 1 of 2 residents reviewed for ADL (activities of daily living) care. (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS) assessment was completed within 14 days of admission for 1 of 4 residents reviewed for MDS assessments. (Resident 12)

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed every 3 months for 3 of 4 residents reviewed for MDS assessments. (Resident 17, 30, and 59)

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified of high blood glucose levels within the physician's ordered call parameters for 1 of 1 resident reviewed for quality of care. (Resident 53)

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled for at least 8 consecutive hours 7 days a week for 2 of 21 days reviewed for staffing. (7/20/25 and 8/3/25)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure PPE (personal protective equipment) was worn correctly and to establish a clean field for wound care supplies for 1 of 6 residents reviewed for infection control. (Resident 21)

Inspectors wroteBased on interview and record review, the facility failed to ensure the daily nurse staffing data was posted at the beginning of each shift on 1 of 6 survey observation dates. (8/10/25)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure baseline care plans were completed within 48 hours after admission for 2 of 2 residents reviewed for baseline care plans. (Resident B and 34)

Inspectors wroteBased on interview and record review, the facility failed to administer an as needed medication for weight gain, to notify the physician of a weight gain and to hold insulin doses per the physician's orders for 2 of 2 residents reviewed for quality of care. (Resident 34 and 68)

Inspectors wrote3. During an observation, on 9/3/24 at 10:51 a.m., Resident B was wearing oxygen at 3 liters. The clinical record for Resident B was reviewed on 9/3/24 at 1:25 p.m. The diagnoses included, but were not limited to, acute and chronic respiratory failure, type 2 diabetes, stage 3 chronic kidney disease, obstructive sleep apnea, and retention of urine. The resident was admitted on [DATE]. While reviewing the resident's physician's orders, the resident did not have an order for the use of oxygen. During an interview, on 9/3/24 at 3:01 p.m., the DON indicated she was not aware the resident did not have an order for oxygen. During an interview, on 9/10/24 at 12:00 p.m., the DON indicated they did not have a policy for physician's orders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessments were completed and a consent was obtained prior to the use of side rails for 2 of 3 residents reviewed for accident hazards. (Resident O and 63)

Inspectors wroteBased on interview and record review, the facility failed to ensure a PRN (as needed) psychotropic medication was not ordered beyond 14 days or the attending physician documented their rationale in the resident's medical record to indicate the duration for the PRN order for 2 of 5 residents reviewed for unnecessary medications. (Resident K and 183)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was being served at proper (safe and appetizing) temperature for 1 of 1 kitchen reviewed for safe food temperatures.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was placed in contact isolation immediately after being tested and while waiting for the results for Clostridium Difficile (C-Diff) for 1 of 1 resident reviewed for antibiotic use. (Resident B)

Inspectors wroteBased 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.

Inspectors wroteBased 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)

Inspectors wrote3. During an observation, on 8/27/23 at 12:33 p.m., QMA 7 was standing next to Resident 40 feeding her. CNA 8 took over feeding the resident and she remained standing until the resident finished. During an observation, on 8/29/23 at 12:33 p.m., the Activity Director was assisting the resident to eat while she was standing next to her. She kneeled on the floor beside the resident at 12:36 p.m., then stood back up to assist her to eat. The record for Resident 40 was reviewed on 8/27/23 at 1:00 p.m. Diagnoses included, but were not limited to, dysphagia and Alzheimer's disease. A care plan, dated 8/15/23, indicated eating may fluctuate throughout the day, but usual performance was supervision or touching assistance. [...]

Inspectors wroteBased on interview and record review, the facility failed to update the care plan for a resident after acquiring a pressure ulcer on his heel for 1 of 3 residents reviewed for pressure ulcers. (Resident 73)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident was getting her teeth brushed twice daily as ordered by the dentist for 1 of 1 resident reviewed for dental care. (Resident 40)

Inspectors wrote3. During an observation, on 8/29/23 at 3:40 p.m., Resident 33 was sitting in her wheelchair, in the dining room, her legs were dangling to the floor and both lower legs were swollen. During an observation and interview, on 8/31/23 at 9:55 a.m., the resident indicated her legs were swollen and they were heavy. The resident's legs appeared to have edema. The record for Resident 33 was reviewed on 8/29/22 at 12:12 p.m. Diagnoses included, but were not limited to, congestive heart failure, chronic kidney disease, and hypertension. A care plan, dated 6/22/22, indicated the resident had an alteration in her nutritional status related to congestive heart failure. The interventions included, but were not limited to, obtain weight as indicated and report to the Registered Dietician, Physician, and family of significant weight changes. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the physician, implement interventions timely and to include re-weights with a date completed in the electronic record (EHR) for significant weight changes for 2 of 5 residents reviewed for nutrition. (Resident 14 and 42)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure an enteral (a feeding directly into the stomach) feeding tube was unclamped and connected to the feeding 1 of 1 resident reviewed for tube feeding. (Resident 50)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident had a physician's order for the administration of oxygen (02) and failed to ensure an oxygen saturation (02 sat) was obtained prior to setting the liter per minute (LPM) flow rate of the oxygen for 1 of 1 resident reviewed for oxygen. (Resident 66)

Inspectors wroteBased on record review and interview, the facility failed to have Certified Nursing Assistants (CNA) coverage for the evening shift to ensure residents on the Memory Care Unit (MCU) received showers during the evening shift for 3 of 3 residents reviewed for evening showers. (Residents 14, 40 and 15)

Inspectors wroteBased on record review and interview, the facility failed to ensure there was RN coverage for multiple days for the 2nd Quarter of 2023 from 1/1/2023 to 03/31/2023.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide a consistent program of cognitively stimulating activities for a resident with dementia for 1 of 4 residents reviewed for dementia care. (Resident 52)

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare pureed foods according to the recipes in the kitchen for 5 of 5 residents who were ordered a pureed diet.