Inspection Reports for
Clinton Healthcare and Rehabilitation Center
1009 EAST OHIO, CLINTON, MO, 64735-2455
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
71 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 2
Date: Mar 26, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to honor residents' shower preferences and missing narcotic pain medication for a resident.
Complaint Details
The complaint investigation found that four residents did not receive showers according to their preferences and that narcotic medication for one resident was missing. The narcotic discrepancy was reported on 03/16/25, and an investigation was conducted including staff interviews and police notification.
Findings
The facility failed to promote and facilitate residents' right to self-determination by not honoring shower preferences for four residents, and failed to protect a resident from misappropriation of narcotic medication when 30 tablets of morphine sulfate went missing while in facility possession.
Deficiencies (2)
Failure to promote and facilitate resident self-determination by not honoring four residents' shower preferences.
Failure to protect resident from misappropriation of narcotic pain medication when 30 tablets of morphine sulfate went missing.
Report Facts
Residents affected: 4
Morphine sulfate tablets missing: 30
Facility census: 71
Morphine sulfate tablets received: 60
Morphine sulfate tablets received: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Reported narcotic count discrepancy on 03/16/25 |
| LPN A | Licensed Practical Nurse | Conducted medication counts and provided statements regarding narcotic count |
| LPN F | Licensed Practical Nurse | Worked shift during narcotic count discrepancy and provided statement |
| LPN D | Licensed Practical Nurse | Provided information on narcotic count procedures and shower aide staffing |
| CNA E | Certified Nursing Assistant | Reported shower aide staffing and shower frequency issues |
| CNA C | Certified Nursing Assistant | Reported lack of communication about residents needing showers |
| Assistant Director of Nursing | Assistant Director of Nursing | Discussed shower aide staffing and narcotic count procedures |
| Director of Nursing | Director of Nursing | Stated expectations for shower frequency and narcotic count compliance |
Inspection Report
Abbreviated Survey
Census: 71
Deficiencies: 5
Date: Feb 10, 2025
Visit Reason
The inspection was conducted to investigate compliance with resident rights, medication management, and facility policies including shower assistance, medication errors, and transfer agreements.
Findings
The facility failed to honor residents' shower preferences, resulting in inadequate showering frequency. There was a missing narcotic medication incident involving morphine sulfate. The facility also failed to accurately transcribe physician medication orders for a resident, resulting in administration of excessive medication doses and subsequent resident death. Additionally, the facility lacked a written hospital transfer agreement.
Deficiencies (5)
Failed to promote and facilitate resident self-determination by not honoring shower preferences for four residents.
Failed to protect resident from misappropriation of narcotic pain medication when morphine sulfate tablets went missing.
Failed to provide care meeting professional standards by inaccurately transcribing physician orders for one resident.
Failed to ensure residents were free from significant medication errors resulting in administration of excessive doses of apixaban and diltiazem to one resident, who subsequently died.
Failed to have a written transfer agreement with at least one hospital to ensure timely admission and information exchange.
Report Facts
Facility census: 71
Morphine sulfate tablets missing: 30
Medication doses administered: 5
Medication doses administered: 360
Facility census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in narcotic medication count discrepancy and medication order transcription |
| LPN B | Licensed Practical Nurse | Named in narcotic medication count discrepancy and interviews about shower aide staffing |
| LPN D | Licensed Practical Nurse | Named in narcotic medication count discrepancy and medication order transcription |
| CNA E | Certified Nursing Assistant | Interviewed regarding shower aide staffing and shower frequency |
| CNA C | Certified Nursing Assistant | Interviewed regarding shower aide staffing and shower frequency |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding shower aide staffing and narcotic medication count procedures |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding shower expectations and narcotic medication count procedures |
| Pharmacy Consultant | Pharmacy Consultant | Identified medication order errors and communicated with facility staff |
| Administrator | Facility Administrator | Interviewed regarding narcotic medication count discrepancy, medication errors, and transfer agreement |
| Regional Director of Operations | Regional Director of Operations | Interviewed regarding lack of written hospital transfer agreement |
| Regional Nurse Consultant | Regional Nurse Consultant (RNC) | Interviewed regarding lack of written hospital transfer agreement |
| Certified Medication Tech A | Certified Medication Technician | Interviewed regarding medication administration and error reporting |
| LPN C | Licensed Practical Nurse | Interviewed regarding medication order entry and medication error reporting |
| RN B | Registered Nurse | Interviewed regarding medication order entry and medication error reporting |
| LPN E | Licensed Practical Nurse | Interviewed regarding medication order entry |
| LPN H | Licensed Practical Nurse | Interviewed regarding new admission medication order verification |
| Interim DON | Interim Director of Nursing | Interviewed regarding medication order entry and chart audits |
| Medical Director | Medical Director | Interviewed regarding medication dosing concerns |
Inspection Report
Routine
Census: 67
Deficiencies: 3
Date: Sep 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on tuberculosis (TB) screening compliance for staff.
Findings
The facility failed to maintain an effective infection control program by not ensuring completion of the two-step tuberculin skin test (TST) for three staff members prior to resident contact, including failure to read the TB test within the required 48 to 72 hours and failure to document prior TB testing within two years.
Deficiencies (3)
Failed to ensure the first and second step of the two-step tuberculin skin test was completed prior to resident contact for three staff members.
Failed to ensure the TB test was read within 48 to 72 hours from placement for one staff member.
Failed to document other TB testing documented in the preceding two years for reviewed staff.
Report Facts
Facility census: 67
Number of staff sampled: 10
Number of staff with incomplete TB testing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Failed to complete second step TB test and lacked documentation of prior TB testing |
| CMT B | Certified Medication Tech | TB test was not read within 48 to 72 hours from placement |
| LPN C | Licensed Practical Nurse | Failed to complete first step TB test prior to resident contact |
| LPN D | Licensed Practical Nurse | Interviewed regarding TB testing procedures |
| LPN E | Licensed Practical Nurse | Interviewed regarding TB testing procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding TB testing procedures and compliance |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding TB testing procedures and compliance |
| Interim Administrator | Interim Administrator | Interviewed regarding TB testing procedures and compliance |
Inspection Report
Routine
Deficiencies: 10
Date: Sep 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, discharge notifications, PASARR assessments, care planning, respiratory care, pain management, dialysis care, pharmaceutical services, and psychotropic medication monitoring.
Findings
The facility was found deficient in multiple areas including failure to implement an effective grievance process, failure to provide written transfer notices, failure to submit new PASARR assessments after new mental illness diagnoses, failure to develop baseline and comprehensive care plans for residents, failure to provide respiratory care as ordered, failure to ensure pain medications were available and administered as ordered, failure to ensure dialysis communication forms were completed, failure to maintain accurate narcotic counts, and failure to monitor side effects and behaviors related to psychotropic medications.
Deficiencies (10)
Failed to implement an effective grievance process with documentation of full investigation, final decision, and follow-up with residents.
Failed to provide written notice of transfer/discharge to resident and/or representative for emergent hospital transfers.
Failed to submit new PASARR Level I assessments after new mental illness diagnoses for two residents.
Failed to develop baseline care plan within 48 hours of admission for resident's schizophrenia diagnosis.
Failed to develop and implement complete care plans addressing all resident needs for multiple residents.
Failed to change nebulizer tubing as ordered for one resident.
Failed to provide effective pain management; pain medications were not available or administered as ordered for four residents.
Failed to ensure dialysis communication forms were completed before and after dialysis for one resident.
Failed to routinely complete documented narcotic counts with signatures at each change of shift.
Failed to monitor side effects and targeted behaviors for residents receiving psychotropic medications.
Report Facts
Residents reviewed for PASARR: 5
Residents sampled: 27
Residents affected by grievance deficiency: Some
Residents affected by transfer notification deficiency: Few
Residents affected by PASARR deficiency: Few
Residents affected by baseline care plan deficiency: Few
Residents affected by care plan completeness deficiency: Some
Residents affected by respiratory care deficiency: Few
Residents affected by pain management deficiency: Some
Residents affected by dialysis communication deficiency: Few
Residents affected by narcotic count deficiency: Some
Residents affected by psychotropic medication monitoring deficiency: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 5 | Licensed Practical Nurse | Mentioned in relation to narcotic record review and medication ordering |
| RN 1 | Registered Nurse | Mentioned in relation to respiratory care, dialysis communication, narcotic record review, and psychotropic medication monitoring |
| LPN 1 | Licensed Practical Nurse | Mentioned in relation to pain medication management and dialysis communication |
| Regional Nurse Consultant (RNC) 1 | Regional Nurse Consultant | Mentioned in relation to pain management and psychotropic medication monitoring |
| Regional Nurse Consultant (RNC) 2 | Regional Nurse Consultant | Mentioned in relation to grievance process and pain management |
| Regional Operations Director (ROD) 1 | Regional Operations Director | Mentioned in relation to grievance process and pain management |
| Administrator | Mentioned in relation to grievance process, transfer notification, pain management, narcotic record review, and psychotropic medication monitoring | |
| Director of Nursing (DON) | Director of Nursing | Mentioned in relation to grievance process, PASARR, care planning, dialysis communication, and psychotropic medication monitoring |
| MDS Coordinator (MDSC) | MDS Coordinator/Director of Nursing | Mentioned in relation to care planning and psychotropic medication monitoring |
Inspection Report
Routine
Census: 61
Deficiencies: 5
Date: Jan 6, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident care, including PASARR screening, baseline care plans, respiratory care, dialysis care, and nurse aide training.
Findings
The facility failed to complete required PASARR screening for one resident, did not develop baseline care plans addressing dialysis and BIPAP use for two residents, failed to obtain physician orders and provide maintenance for a BIPAP machine, did not properly monitor and communicate regarding a resident's dialysis catheter, and allowed three nurse aides to work without completing required CNA training and certification within four months of hire.
Deficiencies (5)
Failed to provide PASARR screening for Mental disorders or Intellectual Disabilities for one resident.
Failed to develop and implement a baseline care plan addressing dialysis port care and BIPAP use for two residents.
Failed to obtain physician's order and provide proper cleaning and maintenance for a BIPAP machine for one resident.
Failed to provide thorough assessments, monitoring, and communication regarding a resident's dialysis central venous catheter and failed to obtain a dialysis contract.
Failed to ensure three nurse aides completed state-approved CNA training and competency evaluation within four months of hire.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Nurse aides without CNA certification: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Named in findings related to baseline care plans and dialysis care |
| Administrator | Named in multiple interviews regarding deficiencies and expectations | |
| Director of Nursing | DON | Named in multiple interviews regarding deficiencies and expectations |
| NA A | Nurse Aide | Named in deficiency for lack of CNA certification |
| NA B | Nurse Aide | Named in deficiency for lack of CNA certification |
| NA C | Nurse Aide | Named in deficiency for lack of CNA certification |
Inspection Report
Routine
Census: 71
Deficiencies: 8
Date: Sep 13, 2019
Visit Reason
The inspection was conducted to assess compliance with Medicare/Medicaid regulations including notification of Medicare Part A coverage and liability, use of physical restraints, care planning, change in condition assessments, catheter care, pain management, physician orders, and dental care.
Findings
The facility was found deficient in multiple areas including failure to provide Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) to residents discharged from Medicare Part A services, failure to assess and obtain physician orders for physical restraints, failure to develop comprehensive care plans timely, inadequate assessment and documentation following resident falls, failure to obtain and follow physician orders for catheter care, incomplete documentation and management of pain medications, delayed physician admission orders, and failure to address dental care needs for a resident.
Deficiencies (8)
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or denial letter at initiation, reduction, or termination of Medicare Part A benefits for two residents.
Failed to assess use of seat belt as a restraint and obtain physician order for one resident.
Failed to develop a comprehensive care plan within 7 days of comprehensive assessment for one resident.
Failed to assess change in condition and complete neurological checks following a fall for one resident; failed to address resident's request for hospital transfer.
Failed to obtain physician order for catheter and catheter care for one resident and failed to follow catheter care orders for another resident.
Failed to fully document administration and effectiveness of pain medications for three residents; failed to notify physician of continued pain for two residents.
Failed to obtain physician admission orders timely for one resident; physician orders signed two months after admission.
Failed to address dental care needs for one resident; resident had dental cavities and no documented dental care plan or timely dental appointments.
Report Facts
Facility census: 71
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Named in pain medication administration and documentation deficiencies |
| CNA F | Certified Nursing Assistant | Responsible for scheduling dental appointments |
| Director of Nursing | Director of Nursing | Provided information on care plan and dental care processes |
| Social Service Director | Social Service Director | Responsible for dental appointment coordination and family contact |
| Certified Medication Technician A | Certified Medication Technician | Provided information on pain medication documentation |
| Licensed Practical Nurse B | Licensed Practical Nurse | Provided information on catheter care and pain management |
| Nurse Practitioner | Nurse Practitioner | Provided information on resident pain management and physician orders |
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