Inspection Reports for
Clinton House Rehabilitation and Healthcare Center

The facility failed to complete timely Minimum Data Set (MDS) assessments for several residents, did not notify physicians of high blood glucose levels as ordered, lacked consistent RN staffing for required hours, failed to post daily nurse staffing data properly, and did not follow proper infection control procedures during wound care.

The investigation was complaint-driven, focusing on staffing issues including RN coverage and nurse staffing data posting. The findings confirmed the complaints with substantiated deficiencies.

The facility failed to ensure a registered nurse was scheduled for at least 8 consecutive hours on two days reviewed (7/20/25 and 8/3/25). Additionally, the facility failed to post daily nurse staffing data at the beginning of each shift on one of six observation dates (8/10/25). The facility did not provide staffing policies prior to exit.

The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey identified a deficiency where the housekeeping office door required two operations to open due to an independent dead bolt and locking doorknob, which could affect 2 residents, 2 staff, and 1 visitor.

The facility was found deficient in multiple areas including failure to complete baseline care plans within 48 hours of admission, failure to administer medications per physician orders, inadequate respiratory care and equipment sanitation, improper use and documentation of bed rails, lack of stop dates on psychotropic medication orders, serving food at unsafe temperatures, and failure to place a resident in contact isolation promptly when testing for C-Diff.

Complaint IN00439641 - No deficiencies related to the allegations are cited. Complaint IN00440622 - No deficiencies related to the allegations are cited. Complaint IN00441593 - Federal/state deficiencies related to the allegations are cited at F804 (food temperature).

The facility was found deficient in multiple areas including baseline care plans not completed within 48 hours of admission, failure to administer medications per physician orders, improper respiratory care and equipment storage, lack of assessments and consents for bedrails, psychotropic medication orders without proper stop dates, food served at improper temperatures, and failure to place a resident in contact isolation promptly while awaiting C-Diff test results.

The complaint investigation found that Resident B was not placed in contact isolation for over 24 hours after being tested for C-Diff, despite physician orders and facility policy requiring contact precautions while awaiting laboratory results.

The facility failed to place a resident in contact isolation immediately after testing for C-Diff and while awaiting results. Personal protective equipment (PPE) was not consistently required during enhanced barrier precautions, contrary to contact isolation protocols.

The facility was found not in compliance with several Life Safety Code requirements including missing delayed egress signage on doors, inaccurate fire alarm system time, missing sprinkler escutcheons, sprinkler clearance issues, obstructed fire extinguisher, damaged corridor door, incomplete smoke barrier door closure, incomplete fire drill documentation, combustible decorations not meeting fire safety standards, and improper use of power strips.

The facility was found deficient in multiple areas including resident rights and dignity, care plan revisions, ADL care, quality of care including skin and weight monitoring, tube feeding management, respiratory care, staffing levels, dementia care programming, pharmacy services, food preparation, and sanitary food handling.

The facility was found deficient in multiple areas including resident dignity and care, care plan updates, dental care, skin and wound care, nutrition and weight monitoring, feeding tube management, oxygen therapy, staffing levels, dementia care activities, medication management, food preparation, and kitchen sanitation.

Complaint IN00404299 was substantiated with federal/state deficiencies cited. Complaints IN00409207 and IN00409597 had no deficiencies related to the allegations.

The facility was found deficient related to complaint IN00404299 for failure to ensure a resident's medications were transcribed and administered as ordered on the hospital discharge record for 1 of 3 residents reviewed (Resident H). No deficiencies were cited for the other two complaints.

This Federal tag relates to Complaint IN00404299.

The facility failed to ensure that a resident's medications were transcribed and administered as ordered on the hospital discharge record. Specifically, Resident H did not receive prescribed insulin, atorvastatin, and gabapentin on specified dates following admission.

The facility was found in substantial compliance with Emergency Preparedness requirements but had deficiencies in emergency power system maintenance, life safety code compliance including egress door locking, emergency lighting testing, sprinkler system maintenance, fire drills, fire door inspections, electrical system maintenance, generator testing, and gas cylinder storage.

The facility was found deficient in multiple areas including failure to obtain physician orders for hospice care upon admission, incomplete significant change assessments, failure to identify skin conditions during weekly assessments, unsafe transportation practices, improper medication storage and labeling, inappropriate use of psychotropic medications, lack of dental service consents, non-compliance with dietary menu preparation, and unsafe water temperatures and damaged bathroom doors.