Inspection Reports for
Clinton Healthcare and Rehabilitation Center
1009 EAST OHIO, CLINTON, MO, 64735-2455
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
9.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
59% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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
Re-Inspection
Census: 74
Deficiencies: 7
Date: Feb 10, 2025
Visit Reason
The inspection was a re-inspection conducted on 02/10/2025 to verify correction of previously cited deficiencies related to medication administration and transfer agreements at Clinton Healthcare and Rehabilitation Center.
Findings
The facility failed to meet professional standards in comprehensive care plans and medication administration, resulting in medication errors and lack of proper transfer agreements. The facility implemented corrective actions and plans of correction were submitted to address these deficiencies.
Deficiencies (7)
F658 Comprehensive care plans did not meet professional standards as staff failed to accurately transcribe physician orders for one resident, leading to medication errors. The facility census was 74.
F760 The facility failed to ensure residents were free of significant medication errors when staff administered medications in excess of ordered dosages and failed to notify the physician. The facility census was 74.
F843 The facility failed to have a written transfer agreement with a hospital to ensure timely admission and information exchange for residents. The facility census was 74.
A4055 The facility failed to maintain a safe and effective medication system, resulting in an imminent danger class I deficiency at the time of complaint investigation, later lowered to class II.
A4060 The facility failed to ensure medication errors and adverse reactions were reported immediately to the nursing supervisor, resulting in a class II deficiency.
A4071 The facility failed to ensure a system of records for controlled drugs was maintained accurately, resulting in missing narcotic tablets and medication count discrepancies.
A4077 The facility failed to ensure residents were groomed and dressed appropriately according to their preferences and medical conditions, resulting in a class II deficiency.
Report Facts
Facility census: 74
Medication tablets missing: 30
Medication tablets counted: 69
Medication tablets delivered: 60
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 2
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) skin testing compliance among staff.
Findings
The facility failed to maintain an effective infection control program by not ensuring timely completion of the two-step TB skin test for sampled staff members. The facility's policies and procedures for communicable disease screening of employees were not met.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to ensure timely completion of the two-step tuberculosis skin test for three staff members, compromising infection control. The facility census was 67 at the time of inspection.
A4031 Communicable Disease-Employees: The facility did not develop and implement policies ensuring employees diagnosed with communicable diseases do not expose residents, violating Missouri Department of Health regulations.
Report Facts
Facility census: 67
Number of staff sampled for TB testing: 10
Completion date for plan of correction: Oct 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in TB skin test compliance review |
| CMT B | Certified Medication Tech | Named in TB skin test compliance review |
| LPN C | Licensed Practical Nurse | Named in TB skin test compliance review |
| 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 |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding TB testing procedures |
| Interim Administrator | Interim Administrator | Interviewed regarding TB testing procedures |
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
Annual Inspection
Census: 69
Deficiencies: 9
Date: Sep 5, 2024
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health, and Senior Services. The facility was found not to be in substantial compliance with 42 CFR 483 subpart B.
Complaint Details
The survey included a complaint investigation related to grievances about staff behavior and failure to follow grievance procedures. The complaint was substantiated as the facility failed to ensure full investigation, final decisions, and follow-up regarding grievances.
Findings
The facility failed to implement an effective grievance process, ensure proper notice before transfer or discharge, coordinate PASARR assessments, develop baseline and comprehensive care plans, provide adequate respiratory care, manage pain effectively, maintain pharmacy records, and monitor psychotropic medication use and side effects.
Deficiencies (9)
F585 The facility failed to implement an effective grievance process including documentation of full investigation, final decision, and follow-up regarding findings with the resident who filed the grievance.
F623 The facility failed to provide proper written notice before transfer or discharge to a resident and/or their representative as required by regulation.
F644 The facility failed to coordinate PASARR assessments and submit required documentation for residents with new mental illness diagnoses.
F655 The facility failed to develop and implement baseline care plans within 48 hours of admission for residents, including instructions for effective person-centered care.
F656 The facility failed to develop and implement comprehensive care plans with measurable objectives and timeframes for residents.
F695 The facility failed to provide respiratory care including tracheostomy care and suctioning consistent with professional standards for residents.
F697 The facility failed to ensure effective pain management for residents, including timely medication administration and proper documentation.
F755 The facility failed to maintain accurate pharmacy records and ensure proper acquisition, dispensing, and administration of drugs and biologicals.
F758 The facility failed to monitor psychotropic medication use and side effects, including documentation and evaluation of targeted behaviors for residents.
Report Facts
Survey Census: 69
Sample Size: 27
Supplemental Residents: 0
Inspection Report
Life Safety
Census: 67
Capacity: 120
Deficiencies: 1
Date: Sep 5, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and Medicare/Medicaid participation requirements.
Findings
The facility was found to be noncompliant with fire safety requirements due to failure to ensure fire rated doors closed completely and latched. The deficient practice had the potential to affect all 67 residents present at the facility.
Deficiencies (1)
K324 Cooking Facilities: The facility failed to ensure fire rated doors closed completely and latched in accordance with NFPA 101 Life Safety Code (2012 edition) 19.3.2.5.5. The kitchen fire door did not close all the way and did not latch.
Report Facts
Residents affected: 67
Total beds: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marianne Strackling | Administrator | Signed the inspection report and plan of correction |
| Maintenance Director | Verified kitchen fire doors did not close and latch during interview |
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
Plan of Correction
Census: 61
Deficiencies: 5
Date: Jan 6, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding PASARR screening, baseline care planning, respiratory care, dialysis, and nurse aide hiring and training at Clinton Healthcare and Rehabilitation Center.
Findings
The facility failed to provide a PASARR screening for one resident, did not develop and implement baseline care plans addressing specific resident needs including dialysis and BIPAP use, failed to obtain proper physician orders and monitoring for respiratory and dialysis care, and did not ensure nurse aides completed required training and certification within four months of hire.
Deficiencies (5)
F645 PASARR Screening for MD & ID was not completed for one resident, failing to meet federally mandated preliminary assessment requirements.
F655 Baseline Care Plan was not developed or implemented to address specific resident needs including dialysis and BIPAP therapy for three residents.
F695 Respiratory/Tracheostomy Care and Suctioning requirements were not met due to lack of physician orders and proper cleaning for a BIPAP machine for one resident.
F698 Dialysis care was deficient as the facility failed to provide thorough assessments, monitoring, and communication with the dialysis center for one resident.
F728 Facility Hiring and Use of Nurse Aide requirements were not met; three nurse aides lacked state-approved training and certification within four months of hire.
Report Facts
Facility census: 61
Deficiencies cited: 5
Inspection Report
Life Safety
Census: 61
Capacity: 120
Deficiencies: 2
Date: Jan 6, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents, focusing on kitchen exhaust hood and grease filter safety.
Findings
The facility failed to maintain the kitchen exhaust hood properly, allowing grease filters to remain with gaps and a hole penetrating the hood, which could increase fire risk. The range hood certification requirement was also not met.
Deficiencies (2)
42 CFR 483.90(a) and NFPA 96: The facility failed to maintain the kitchen exhaust hood by allowing grease filters to have gaps and a hole, increasing fire risk. The filters were not flush and had multiple gaps, violating safety standards.
19 CSR 30-85.022(9) Range Hood Certification: The facility did not provide evidence that the range hood and extinguishing system were certified at least twice annually as required by NFPA 96, 1998 edition.
Report Facts
Grease filter gaps: 5
Census: 61
Total capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding kitchen staff practices for cleaning and replacing grease filters | |
| Maintenance Director | Interviewed regarding maintenance staff practices for cleaning grease filters | |
| Administrator | Interviewed regarding procedures for cleaning and maintaining hood filters |
Inspection Report
Plan of Correction
Census: 65
Deficiencies: 3
Date: Aug 29, 2022
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies cited during a survey conducted on 08/29/2022 at Clinton Healthcare and Rehabilitation Center.
Findings
The facility was found not free from abuse and neglect, with evidence of verbal and physical abuse by staff towards residents. The facility also failed to report alleged violations of abuse promptly as required by regulations.
Deficiencies (3)
F600: The facility failed to ensure all residents were free from abuse, neglect, and exploitation, including verbal and physical abuse by a Certified Nurse Aide towards a resident.
F609: The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment immediately and within required timeframes to the appropriate authorities.
F610: The facility failed to immediately investigate and take steps to protect residents during an abuse investigation involving verbal abuse by a staff member towards a resident.
Report Facts
Facility census: 65
Date of survey: Aug 29, 2022
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 23, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 1
Date: Jul 7, 2021
Visit Reason
The document is a plan of correction submitted by Clinton Healthcare and Rehabilitation Center following a deficiency cited during a survey completed on 07/07/2021.
Findings
The facility failed to ensure resident safety during transportation, resulting in a resident sustaining a C-2 fracture after a fall caused by improper securing in a transport van. The deficiency involved failure to use all four wheelchair tie down straps as required by facility policy.
Deficiencies (1)
F 689 Free of Accident Hazards/Supervision/Devices. The facility failed to properly secure a resident in the transport van, resulting in a fall causing a C-2 fracture. The policy did not address resident safety during transportation adequately.
Report Facts
Facility census: 67
Date of incident: Jan 21, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Assistant | Named in the finding for improper securing of resident during transport |
| Social Service Designee | SSD | Provided information about facility transport procedures |
| Director of Nursing | DON | Notified of the incident and participated in interviews |
| Medical Director | Interviewed regarding expectations for transport safety | |
| CNA B | Certified Nurse Assistant | Trained by SSD and involved in transport safety interviews |
| Administrator | Notified of the immediate jeopardy and participated in interviews |
Inspection Report
Routine
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
This was a complaint investigation related to COVID-19 infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Jul 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
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 |
Inspection Report
Plan of Correction
Census: 71
Deficiencies: 8
Date: Sep 13, 2019
Visit Reason
The document is a Plan of Correction submitted by Clinton Healthcare and Rehabilitation Center following a survey conducted on 09/13/2019. It addresses deficiencies cited during the inspection.
Findings
The facility was found deficient in multiple areas including failure to provide required notices to Medicaid-eligible residents, improper use of physical restraints, incomplete comprehensive care plans, inadequate pain management documentation, and failure to ensure dental services. The facility census was 71 at the time of the survey.
Deficiencies (8)
F-582 Medicaid/Medicare Coverage/Liability Notice. The facility failed to provide Skilled Nursing Facility Advance Beneficiary Notice or denial letters for two residents who remained after discharge from Medicare Part A services.
F-604 Right to be Free from Physical Restraints. The facility failed to assess the use of a seat belt restraint and obtain a physician order for one resident who could not remove the seat belt without assistance.
F-657 Care Plan Timing and Revision. The facility failed to develop a comprehensive care plan for one resident out of a sample of 18 residents.
F-684 Quality of Care. The facility failed to assess a resident's catheter following a fall and failed to address the resident's request to be discharged to the hospital.
F-690 Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to obtain an order for a catheter and failed to follow orders for catheter care for one resident.
F-697 Pain Management. The facility failed to fully document administration and effectiveness of pain medications for three residents in a sample of 18.
F-710 Resident's Care Supervised by a Physician. The facility failed to obtain a physician's admission orders in a timely manner for one resident.
F-790 Routine/Emergency Dental Services in SNFs. The facility failed to address dental needs for one resident out of a sample of 18 residents.
Report Facts
Facility census: 71
Sample size: 18
Deficiency completion dates: Most corrective actions completion dates are 10/20/2019
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 13, 2019
Visit Reason
This document is a plan of correction submitted in response to a Life Safety Code survey conducted at Clinton Healthcare and Rehabilitation Center.
Findings
The Emergency Preparedness portion of the survey did not result in deficiencies. The facility met applicable provisions of the 2012 edition of the Life Safety Code. No state licensure deficiencies were cited during this inspection.
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 4
Date: Nov 16, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding quality of care and infection control at Clinton Healthcare and Rehabilitation Center.
Findings
The facility failed to communicate changes in residents' conditions to hospice for two residents and did not provide required pneumococcal vaccinations or education to residents or their representatives. Deficiencies were cited related to quality of care and infection control.
Deficiencies (4)
F684 Quality of care deficiency: The facility failed to communicate changes in residents' conditions for two hospice residents, including failure to notify hospice of clinical changes and document such communication.
F883 Infection control deficiency: The facility failed to offer pneumococcal vaccines and provide education to residents or their representatives, and did not document vaccine administration or refusals for three residents.
A4074 Nursing care per resident condition deficiency: Residents did not receive personal attention and nursing care consistent with their condition and accepted nursing practice.
A4085 Infection control/communicable disease deficiency: The facility failed to report communicable diseases to the state health department as required.
Report Facts
Facility census: 65
Residents not offered pneumococcal vaccine: 3
Inspection Report
Life Safety
Deficiencies: 0
Date: Nov 16, 2018
Visit Reason
The inspection was conducted as an Emergency Preparedness survey and a Licensure Inspection to assess compliance with life safety codes and state licensure requirements.
Findings
No deficiencies were cited as a result of the Emergency Preparedness survey or the Licensure Inspection. The facility meets the applicable provisions of the 2012 edition of the Life Safety Code.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Hudson | Administrator/CEO | Signed the statement of deficiencies and plan of correction |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 4
Date: Jan 4, 2018
Visit Reason
The inspection was conducted due to complaints regarding maintenance of a safe, clean, and comfortable environment and failure to meet professional standards in medication administration.
Complaint Details
Complaint investigation #MO00137013 and #MO00136905 regarding environmental cleanliness and medication administration. The complaints were substantiated based on observations and record reviews.
Findings
The facility failed to maintain a clean and comfortable environment for residents, including issues with housekeeping and infection control. Additionally, the facility did not ensure proper documentation and administration of intravenous medications for two residents.
Deficiencies (4)
F584 Safe Environment: The facility failed to maintain a clean and comfortable environment, including unclean resident rooms and improper housekeeping practices. Resident #3's room was found with trash and soiled items on the floor and surfaces.
F658 Services Provided Meet Professional Standards: The facility failed to ensure staff documented administration of intravenous medications per physician orders for Residents #1 and #2. Multiple missed documentation and improper handling of PICC lines were noted.
A3039 Rooms Neat, Orderly, Cleaned Daily: Rooms were not kept neat, orderly, or cleaned daily as required, contributing to the unsafe environment. This deficiency is linked to F584.
A4074 Nursing Care per Resident Condition: The facility failed to provide nursing care consistent with resident conditions, including proper medication administration and monitoring. This deficiency is linked to F658.
Report Facts
Facility census: 60
Residents sampled: 5
Residents sampled: 6
Missed medication documentation days: 9
Missed medication documentation days: 5
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