Clinton Therapy & Living Center

Inspectors wroteBased on record review and interview, the facility failed to provide a SNF ABN to 2 (#3 and #26) of 3 sampled residents whose beneficiary notices were reviewed. The administrator identified four residents who were discharged from the facility with Medicare benefit days remaining.

Inspectors wroteBased on record review and interview, the facilty failed to transmit MDS assessment data to CMS in the required timeframe for 4 (#7, 10, 21, and #23) of 12 sampled residents reviewed for MDS assessments. The administrator identified 28 residents resided at the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered for one (#21) of 5 sampled residents reviewed for unnecessary medications. The administrator identified 28 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to accurately code MDS assessment data for 2 (#10 and #6) of 12 sampled residents reviewed for MDS assessments. The administrator identified 28 residents resided at the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician orders for oxygen therapy where obtained for 1 (#3) of 12 sampled residents who were reviewed for physician orders. The administrator identified 28 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain a physician's order for a catheter for 1 (#25) of 1 sampled resident reviewed for indwelling catheters. The DON identified 28 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure a multidose vial of a PPD solution was dated upon opening 1 of 1 medication storage room observed. The DON identified 28 residents resided in the facility.

Inspectors wroteOn 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. The DON identified two residents with a high risk for wandering and elopement.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and update a care plan with interventions for wandering and elopement for 1 (#1) of 3 sampled residents reviewed for wandering and elopement. The DON identified two residents with a high risk for wandering and elopement.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure allegations of abuse were reported to OSDH within two hours of the allegation for three (#13, 24 and #82) of three sampled residents who were reviewed for reporting timely abuse allegations. The administrator identified 31 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an allegations of abuse were investigated for two (#13 and #24) of three sampled residents who were reviewed for investigating allegations of abuse. The administrator identified 31 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facilty failed to transmit MDS assessment data to CMS in the required timeframe for two (#7 and #23) of 12 sampled residents reviewed for MDS assessments. The administrator identified 31 residents resided at the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the dish machine temperature and sanitizer concentration and refrigeration temperatures were monitored and logged daily to ensure safe operation and safe storage of potentially hazardous foods during two of two of two kitchen observations. The DON identified 29 residents received nutrition and hydration from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident and/or their legal representative was informed in writing of treatments and side effects of the use of psychotropic medications for one (#24) of five sampled residents who were reviewed for education, alternative treatments, and consents for psychotropic medication treatments. The DON identified 11 residents who had diagnosis of dementia and 18 residents who received psychotropic medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a clean, safe, and comfortable home like environment for residents. The administrator identified 31 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to prevent sexual abuse for one (#13) of three sampled residents who were reviewed for abuse. The administrator identified 31 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement their abuse policy by: a. not reporting abuse to the administrator and investigating immediately; and b. not taking steps to prevent further abuse for two (#13 and #82) of three sampled residents who were reviewed for abuse. The administrator identified 31 residents resided in the facility.

Inspectors wroteBased on record review, and interview, the facility failed to ensure hospice services was care planned for one (#31) of three sampled residents reviewed for closed record review. The administrator identified 31 residents resided at the facilty.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were supplied as ordered for one (#5) of five sampled residents observed during medication administration pass. The administrator identified 31 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a physician order was completed for one (#14) of five sampled residents reviewed for unnecessary medications. The DON identified 18 residents who received psychotropic medications.

Inspectors wroteOn 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. On 09/08/24 at 4:10 p.m., Res #1 remained with 15 minute checks, but was last observed by staff at 4:20 p.m. Staff were unable to locate Res #1 at 4:43 p.m. [...]

Inspectors wroteBased on record review and interview, the facility failed to update a care plan after an assessment for high risk of elopement and a documented event of a missing resident for one (#1) of four sampled residents reviewed for care plans. The DON identified the census was 32.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure supervision to prevent an elopement for one (#3) of three sampled residents reviewed for elopement. The Administrator identified 31 residents resided in the facility. The MDS coordinator identified three residents who were at risk for elopement.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an effective pest control for four (#1, #4, #6 and #7) of four sampled residents reviewed for pest control. The Administrator identified 31 residents resided in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure staff followed their policy to report an allegation of abuse to the Administrator for one (#10) of four sampled residents reviewed for abuse. The Administrator identified 31 residents resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rights were posted. This had the potential to affect 35 residents in the facility. LPN #1 identified the census was 35.

Inspectors wroteBased on observation, record review, and interview, the facility failed to: a. assess a resident's physical limitations to prevent psychological abuse, and b. follow their abuse policy to fully investigate and report allegations of neglect for one (#5) of three residents reviewed for abuse. LPN #1 identified the facility census was 35.

Inspectors wroteThe facility failed have a system in place to ensure medications were available for one (#1) of three sampled residents reviewed for medication availability. LPN #1 stated the facility census was 35.

Inspectors wroteBased on record review and interview, the facility failed to coordinate care and services with mental health providers for one (#1) of three residents reviewed for mental health services. The facility census was 35.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident receiving 1:1 supervision was free from confinement, restriction, or isolation for one (#1) of one sampled resident who was reviewed for involuntary seclusion. The administrator identified 35 residents resided in the facility.

Inspectors wrote5. Resident # 8 had diagnoses which included Alzheimer's, schizoaffective bipolar type, and mood disorder. A Brief Interview for Mental Status assessment, dated 07/21/23, documented Resident # 8's cognition was moderately impaired. A Progress Note, dated 08/01/23, at 9:00 p.m., documented Resident #14 hit Resident #8 two times on the right side of Resident #8's face. An Incident Report, dated 08/02/23, documented Resident # 8 was hit by Resident #14. The clinical health record did not document the physician or police had been notified. On 08/28/23 at 4:16 p.m., the DON was asked about the incident, on 08/01/23. The DON reviewed the clinical health record and stated Resident #8 notified the police on 08/02/23 at 9:59 p.m. The DON was asked if the physician was notified of the incident. [...]

Inspectors wrote2. Resident #14 was admitted with diagnoses to include dementia with psychotic disturbance, cerebral vascular disease, tobacco use, hypo-osmolality and hyponatremia, alcohol dependence, and bipolar disorder. A Progress Note, dated 05/20/23 at 4:30 p.m., read in parts, .Received a call from [local police department] that resident was across the street at [another local nursing home] .Staff member from this facility walked over to return resident .Resident will be 1 on 1 till end of shift and will notify oncoming nurse of cont (sic) intervention . The clinical record contained no documentation Resident #14 had been supervised with one on one staff as indicated in the progress note. The record contained no incident report or a report to OSDH for regarding Resident #14's elopement. No further information was provided by the facility. [...]

Inspectors wroteBased 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. residents were free from abuse and neglect, allegations and known events were identified, victims were protected during investigation, thorough investigations were completed and reported the to required agencies within the required time frame, e. [...]

Inspectors wroteBased on record review and interview, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for the residents completely both day-to-day operations and emergencies. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility. Findings. On 08/15/23 at 2:30 p.m., the Administrator and Corporate Nurse were provided an Entrance Conference Worksheet, and provided verbal instructions to provide a Facility Risk Assessment. On 08/28/23 at 1:50 p.m., the Corporate Nurse was asked to provide the Facility Risk Assessment. The Corporate Nurse stated, I have been looking for it because I knew you would ask. I cannot find one.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were provided dignity for: a. two (#5 and #21) of three sampled residents that required assistance with toileting needs and; b. one (#3) of three sampled residents reviewed for dignity. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility and documented eight residents were dependent on staff for toileting, 18 residents required assistance for toileting, and 22 residents were in a chair all or most of the time.

Inspectors wroteBased on record review and the interview, the facility failed to: a. ensure advanced directives were offered for one ( #13) of 16 sampled residents reviewed for advanced directives, and b. ensure code status for DNR or CPR was accurately documented in the clinical health record for two (#4 and #13) of 16 sampled residents reviewed for code status. The Resident Census and Condition of Residents report, dated [DATE], documented 37 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure a NOMNC and ABN was provided for a facility initiated discharge from Medicare Part A services with days remaining for three (#15, 24, and #58) of three sampled residents reviewed for beneficiary notices. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility. The Entrance Conference Worksheet, undated, documented 12 residents were discharged from Medicare Part A services with days remaining in the last six months.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe homelike environment to ensure: a. blue painters tape was not used to repair a broken toilet in room [ROOM NUMBER]'s bathroom, b. tiles in the common area were not missing, cracked, stained, and buckled from water damage in common areas accessed by residents, and c. electrical outlets were covered in room [ROOM NUMBER]'s bathroom next to the sink The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to complete comprehensive resident assessments within 14 days of admission to the facility for three (#14, 21, and #151) of three sampled residents reviewed for comprehensive assessments. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility. 1. Resident #14 was admitted to the facility, on 05/20/23, with diagnoses to include dementia, emphysema, respiratory failure, alcohol dependence, and bipolar disorder. The resident assessment logs, documented: a. an entry to the facility was initiated on 05/20/23; and b. an admission assessment was initiated on 05/20/23 and remained in progress. 2. Resident #21 was admitted to the facility, on 07/18/23, with diagnoses to include bacteremia, diabetes mellitus, encephalopathy, and respiratory failure. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident assessments were transmitted within 7 days of completion for three (#17, 13, and #9) of three sampled residents reviewed for the transmission of resident assessments. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility. 1. The Resident Assessment and Transmission Logs for Resident #17, documented: a. On 03/28/23, a Medicare 5-day Assessment had been exported but not accepted, and b. On 04/03/23, an End of Medicare Part A Stay Assessment had been exported but had not been accepted. 2. The Resident Assessment and Transmission Logs for Resident #13, documented: a. On 03/24/23, a Medicare 5-day Assessment had been exported but not accepted, and b. On 04/20/23, an End of Medicare Part A Stay Assessment had been exported but not accepted. 3. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure baseline care plans were completed for two (#14 and #21) of three sampled residents reviewed for baseline care plans. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility. 1. Resident #14 had been admitted to the facility, on 05/20/23, with diagnosis to include dementia, cerebral vascular disease, bipolar disorder, alcohol dependence, emphysema and respiratory failure. The clinical record did not contain a baseline care plan. On 08/24/23 at 2:25 p.m., the Administrator was asked what interventions were placed for Resident #14 on the baseline care plan. They stated there is not a baseline care plan. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive care plans were completed for two (#14 and #21) of three sampled residents reviewed for comprehensive care plans. The Resident Census and Condition of Residents, report, dated 08/16/23, documented 37 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure ADL care was provided for dependent residents for three (#5, 6, and #9) of five sampled residents reviewed for ADL's. The Resident Census and Conditions of Residents report, dated 08/16/23, documented the 37 residents resided in the facility. Six residents were dependent for bathing and 18 required assistance. Eight residents were dependent for assistance with toileting and eleven required assistance.

Inspectors wroteBased on record review and interview the facility failed to monitor for side effects related to the use of psychotropic and opioid medications for three (#53 7, and #21) of five sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Residents report, dated on 08/16/23, documented 37 residents resided in the facility, and 18 residents received psychoactive medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure a psychotropic medication was not prescribed on an as needed bases for greater than 14 days without a physician documented rationale for two (#3 and #21) of five sampled residents reviewed for unnecessary medications. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility, and 18 residents received psychoactive medications.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure: a. vaccinations were not beyond the expiration date, and b. controlled medications that were to be destroyed were stored in a double lock. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food items in the refrigerator were labeled with the date for one of three refrigerators observed. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility. The Corporate Nurse #1 identified 37 residents received nutrition from the kitchen.

Inspectors wroteBased on record review, and interview, the facility failed to ensure a QAPI program was in place to identify areas of concerns or deficient practice, implement plans of correction, or improve the identified concerns with resident care. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility. On 08/15/23 at 2:30 p.m., the Administrator and Corporate Nurse were provided an Entrance Conference Worksheet, and given verbal instruction to provide information regarding the QAA committee and the facility's QAPI plan. On 08/28/23 at 4:08 p.m., the Corporate Nurse, DON, and ADON were asked what members are included on the QAPI committee. The Corporate Nurse stated, the medical director, social services, Administrator, DON, DM, maintenance, and MDS coordinator. The Corporate Nurse was asked how often the QAPI committee meet. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure Tuberculin tests were administered according to policy for four (#55, 21, 3, and #7) of five sampled residents reviewed for immunizations. The Resident Census and Condition of Residents report, dated 08/16/23 documented 37 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents were offered the pneumococcal vaccination for four (#55, 21, 3, and #7) of five sampled residents reviewed for pneumococcal vaccinations. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility, and 10 residents had received the pneumococcal vaccination.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were offered the COVID-19 vaccination for five (#55, 56, 21, 3, and #7) of five sampled residents reviewed for COVID-19 vaccinations. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain a functioning call light system for two (#5 and #4) of sixteen sampled residents reviewed for a functioning call light system. The Resident Census and Condittion of Residents report, dated 08/16/23, documented 37 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop, implement, and maintain a staff education plan for six (CNA #1, CNA #4, CNA #5 ,CNA #7, the CDM, and the Administrator) of six sampled employees for staff education. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to honor the resident's choice of bathing for one (#18) on one sampled resident reviewed for preference of bathing. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to have information posted through out the facility on how to file a grievance, who the contact person was and have grievance forms readily available for residents or representatives to obtain. The Resident Census and Condition of Residents report, dated 08/16/23, documented 37 residents resided in the facility

Inspectors wroteBased on record review, and interview, the facility failed to complete an accurate comprehensive assessment, maintain comprehensive care plans to include personal interventions, and follow physician order for a psychology referral for one (#14) of two sampled residents reviewed for behavioral health. The Resident Census and Conditions of Residents report, dated 08/16/23, documented 37 residents resided in the facility, 18 residents had behavioral healthcare needs, and none of the 18 residents had an individualized care plan to support the resident.