Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clinton House Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not schedule an RN for at least 8 consecutive hours on two days, despite having residents who required IV medications and higher acuity care. The DON confirmed the absence of RN coverage on those days, and no staffing policy was provided during the survey.
A resident with COPD, dementia, and CHF had an entry MDS completed, but the admission comprehensive MDS assessment remained in progress and was not completed within the required 14-day timeframe. The MDS Coordinator stated the assessment was overdue by 30 days and confirmed the facility followed the RAI manual.
Quarterly MDS assessments were not completed within the required 3-month timeframe for 3 residents. One resident had hemiplegia/hemiparesis, DM2, vascular dementia, and anxiety; another had hydrocephalus, paraplegia, and mild dementia; and a third had autistic disorder and epilepsy. The MDS Coordinator stated the facility followed the RAI manual, which requires quarterly assessments within 3 months.
Failure to notify MD of high blood glucose readings: A resident with morbid obesity, type 2 DM, and HTN had multiple BG readings above the ordered call threshold for Admelog sliding-scale insulin, including readings of 496, 401, 417, and 416, with no documentation that the MD was notified. The DON could not locate documentation of the notifications, and an LPN stated the MD should have been notified and the notification documented in the resident’s record.
Improper PPE Use and Unclean Field During Wound Care: A Unit Manager performed wound care for a resident on EBP with a gown and gloves, but the gown was not tied at the waist and wound care supplies were placed on an unclean bedside table next to a urinal containing urine. The resident had type 2 DM, rhabdomyolysis, and a cognitive communication deficit, and the DON and UM later discussed the gown and urinal handling.
The facility did not ensure that daily nurse staffing data was posted at the beginning of each shift, resulting in outdated information being displayed. The process for posting staffing data relied on manual updates by the scheduler and manager on duty, which led to lapses when sheets were not pulled forward as required. No policy on nurse staffing data posting was provided during the survey.
The facility failed to complete baseline care plans within 48 hours for two residents. One resident, with multiple health issues including respiratory failure, lacked a baseline care plan for oxygen use. Another resident, readmitted after a hospital discharge, did not have a new baseline care plan documented. This was against the facility's policy requiring baseline care plans to be initiated within 48 hours of admission.
The facility failed to administer medication and notify the physician for two residents. One resident with congestive heart failure experienced significant weight gains without receiving prescribed diuretics or physician notification. Another resident with diabetes received insulin despite blood glucose levels being below the hold threshold. Facility policies on medication administration and physician notification were not followed.
The facility failed to properly store and sanitize respiratory equipment for three residents. A resident's nebulizer mask was not stored in a bag, another resident's CPAP/BiPap mask was found on the floor and not sanitized, and a third resident was using oxygen without a physician's order. The facility's policy required masks and tubing to be stored in a plastic bag when not in use.
The facility failed to complete assessments and obtain informed consent before using side rails for two residents. Despite assessments indicating no need for side rails, they were observed in use without documented consent or explanation of risks and benefits. This oversight contravened the facility's policy requiring such measures before bed rail installation.
The facility failed to ensure PRN psychotropic medications had stop dates for two residents. One resident had alprazolam orders without a stop date, and another had clonazepam orders lacking an end date. The DON and Clinical Support nurse acknowledged the oversight, which violated the facility's policy requiring PRN psychotropics to have a stop date within 14 days unless justified by the prescribing practitioner.
The facility failed to serve food at safe temperatures, as observed during a survey. A resident reported late delivery of room trays, resulting in cold food. Observations showed room trays delivered past the lunch period, with temperatures outside safe ranges. Multiple residents expressed concerns about cold food in rooms, discussed in resident council meetings. The facility's policy on food temperatures was not adhered to.
A resident suspected of having Clostridium Difficile (C-Diff) was not placed in contact isolation immediately after testing, contrary to physician orders and facility policy. Instead, the resident was on enhanced barrier precautions, which do not require PPE every time someone enters the room. The Director of Nursing confirmed that contact isolation should have been implemented while awaiting test results.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least 8 consecutive hours per day, 7 days a week, as required. Review of staffing schedules revealed that no RN was present in the facility on two specific Sundays. The facility assessment indicated that there were residents who required IV medications on average, and staff with specialized training, such as RNs, were to be assigned to areas with higher acuity needs. During an interview, the Director of Nursing confirmed that there was no RN present on the identified dates. The facility did not provide a staffing policy prior to the survey exit.
Delayed Admission MDS Assessment
Penalty
Summary
The facility failed to ensure a comprehensive MDS assessment was completed within 14 days of admission for Resident 12. Resident 12’s clinical record showed diagnoses including COPD, dementia, and CHF, and an entry MDS assessment was completed on 6/30/25. An admission MDS assessment with an ARD of 7/13/25 was still in progress and had not been completed as of 8/12/25. During interview, the MDS Coordinator stated the admission comprehensive MDS assessment was overdue by 30 days and should have been completed by 7/13/25, and confirmed the facility followed the RAI manual for policy.
Quarterly MDS Assessments Not Completed on Time
Penalty
Summary
Quarterly MDS assessments were not completed within the required 3-month timeframe for 3 of 4 residents reviewed. Resident 17 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, moderate vascular dementia with psychotic and mood disturbance, and anxiety disorder. After the annual comprehensive MDS assessment, the first quarterly assessment was completed on 4/6/25, but the next quarterly assessment was not completed until 8/11/25, 127 days later. Resident 30 had diagnoses including hydrocephalus, paraplegia, and mild dementia with mood disturbance. After the annual comprehensive MDS assessment, the first quarterly assessment was completed on 4/8/25, and the next quarterly assessment was completed on 8/8/25, 122 days later. Resident 59 had diagnoses including autistic disorder and epilepsy without status epilepticus. After the annual comprehensive MDS assessment, the first quarterly assessment was completed on 4/10/25, and the next quarterly assessment was completed on 8/8/25, 120 days later. During interview, the MDS Coordinator stated the facility followed the RAI manual and that the quarterly assessment should have been completed within 3 months.
Failure to Notify MD of High Blood Glucose Readings
Penalty
Summary
The facility failed to ensure the physician was notified of high blood glucose readings within the ordered call parameters for one resident with morbid obesity, type 2 diabetes, and hypertension. A physician’s order dated 7/22/25 directed staff to give Admelog insulin per sliding scale and to call the MD if the blood glucose was 401 or more. The resident had blood glucose readings of 496 on 7/23/25 at 11:29 a.m., 401 on 7/31/25 at 4:40 p.m., 417 on 8/6/25 at 9:18 p.m., and 416 on 8/7/25 at 8:43 p.m., with no documentation that the MD was called for any of these readings. During interviews, the DON stated that physician notification would be scanned into the miscellaneous tab, documented in notes, or attached to the order and visible in the administration record, but she could not locate documentation of notifications for the high blood glucose readings in the record. An LPN stated that the MD should have been notified when there were call orders and that the notification should have been documented in the resident’s record. The facility policy on Notification of Resident’s Change in Condition stated that the nurse will notify the resident’s attending physician or physician on call when there is specific instruction to notify the physician of changes in the resident’s condition.
Improper PPE Use and Unclean Field During Wound Care
Penalty
Summary
The facility failed to ensure PPE was worn correctly and failed to establish a clean field for wound care supplies for one resident who was reviewed for infection control. During an observation, the Unit Manager gathered wound care supplies, including an antiseptic wound cleanser, gauze pads, calcium alginate with silver, and a foam bordered dressing, and then put on a gown and gloves before performing wound care for the resident. The gown was not tied closed around the waist, and the wound care supplies were placed on the resident’s bedside table without the surface being cleaned first. The supplies were set next to a urinal containing approximately 200 milliliters of urine, and the bedside table was later placed within the resident’s reach after the treatment. The resident had diagnoses including type 2 diabetes mellitus, rhabdomyolysis, and cognitive communication deficit. A physician’s order required enhanced barrier precautions with a sign posted to ensure a gown and gloves were used during identified high-contact care activities. The Unit Manager stated she was not aware the gown had waist ties and said the gown should have been tied around the waist. She also stated the urinal should have been removed from the bedside table before the wound care treatment. The DON stated the urinal had been emptied before the treatment and that if the gown had ties around the waist, it should have been tied.
Failure to Post Current Nurse Staffing Data at Shift Start
Penalty
Summary
The facility failed to ensure that daily nurse staffing data was posted at the beginning of each shift on one of six survey observation dates. On the specified date, the posted nurse staffing data sheet was found to be outdated, displaying information from two days prior. According to the DON, the scheduler was responsible for creating and posting the daily staffing forms each morning, while on weekends, the manager on duty was supposed to post the pre-prepared sheets. However, the process relied on manually pulling forward the correct sheet each day, and if this was not done, the posted information would not reflect current staffing, especially in cases of call-ins or shift changes. The facility was unable to provide a policy on nurse staffing data posting prior to the survey exit.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for two residents. Resident B, who was observed wearing oxygen at 3 liters, did not have a baseline care plan for the use of oxygen despite being admitted with diagnoses including acute and chronic respiratory failure, type 2 diabetes, stage 3 chronic kidney disease, obstructive sleep apnea, and retention of urine. The Chief Nursing Officer confirmed the absence of a respiratory baseline care plan for Resident B, which was against the facility's policy requiring the initiation of a baseline care plan within 48 hours of admission. Similarly, Resident 34, who had diagnoses including pneumonia, acute on chronic systolic congestive heart failure, major depressive disorder, chronic kidney disease stage 3, and anxiety disorder, did not have a new baseline care plan upon readmission to the facility. The resident was initially admitted and had a baseline care plan meeting recorded, but after being discharged to the hospital and readmitted, no new baseline care plan meeting was documented. The Social Services Director confirmed that baseline care plan meetings were recorded in the clinical record, yet this was not done for Resident 34 upon readmission.
Failure to Administer Medication and Notify Physician
Penalty
Summary
The facility failed to administer an as-needed medication for weight gain and did not notify the physician of significant weight changes for two residents. Resident 34, who had diagnoses including pneumonia, acute respiratory failure, congestive heart failure, and chronic kidney disease, was supposed to be weighed daily with physician notification required for specific weight gains. Despite documented weight increases exceeding the thresholds, the facility did not administer the prescribed furosemide or notify the physician. The resident reported issues with breathing and leg swelling, which were not addressed as per the physician's orders. For Resident 68, who had multiple diagnoses including diabetes and vascular dementia, the facility failed to hold insulin doses as ordered when blood glucose levels were below 200. The MAR indicated that insulin was administered on numerous occasions despite blood glucose readings being below the threshold. This was confirmed by an LPN and the DON, who acknowledged that insulin was given against the hold order multiple times. The facility's policies on physician notification and medication administration were not followed, contributing to these deficiencies. The policies required physician notification based on assessment findings and adherence to medication orders, which were not observed in these cases. The lack of adherence to these protocols resulted in the failure to provide appropriate care as per the residents' medical needs and physician directives.
Improper Storage and Lack of Orders for Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and sanitation of respiratory equipment for three residents. Resident 58's nebulizer mask was found lying on top of the nebulizer machine instead of being stored in a bag. The resident had a history of traumatic brain injury and acute respiratory failure with hypoxia, and had a physician's order for albuterol sulfate via nebulizer. Both a CNA and the Director of Nursing acknowledged that the mask was not stored appropriately. Resident 27's CPAP/BiPap mask was observed on the floor and was not sanitized before being placed back on the machine. The resident, who had unspecified asthma and chronic respiratory failure with hypoxia, did not have an order or care plan for the CPAP/BiPap machine, despite using it every night. Additionally, Resident B was observed wearing oxygen at 3 liters without a physician's order. The Director of Nursing was unaware of the lack of an order for oxygen and indicated there was no policy for physician's orders. The facility's policy required that nebulizer, BiPap, CPAP masks, and oxygen tubing be stored in a plastic bag when not in use.
Failure to Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that proper assessments and informed consent were obtained before the use of side rails for two residents, identified as Resident O and Resident 63. For Resident O, observations on multiple dates revealed that a side rail was in use despite a previous assessment indicating that the resident did not require it for bed mobility. The clinical record lacked documentation of any discussion of risks and benefits with the resident or obtaining consent. Additionally, a physical therapy note indicated the use of the bedside rail during therapy, suggesting its use without proper authorization. Similarly, for Resident 63, observations confirmed the presence of a side rail without documented consent or explanation of risks and benefits. The side rail assessment form for this resident was incomplete, with no indication that the resident or their representative had been informed or agreed to the use of the side rail. The facility's policy required an assessment and informed consent before the installation of bed rails, which was not adhered to in these cases.
Failure to Ensure PRN Psychotropic Medications Have Stop Dates
Penalty
Summary
The facility failed to ensure compliance with regulations regarding PRN psychotropic medications for two residents. Resident K had a series of physician's orders for alprazolam, an anti-anxiety medication, with the most recent order lacking a stop date. The Director of Nursing (DON) acknowledged the oversight and confirmed the absence of documented clinical reasoning from the physician for the extended duration of the PRN orders. Resident K's medical history included conditions such as hemiplegia, fibromyalgia, type 2 diabetes, major depressive disorder, insomnia, anxiety disorder, PTSD, and unspecified psychosis. Similarly, Resident 183 had a physician's order for clonazepam, another anti-anxiety medication, without an end date. The DON and the Clinical Support nurse both recognized the absence of a stop date, which is contrary to the facility's policy that requires PRN psychotropics to have a stop date within 14 days unless a clinical rationale is provided by the prescribing practitioner. Resident 183's diagnoses included severe bipolar disorder with psychotic features, type 2 diabetes, and irritable bowel syndrome.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at proper temperatures, as observed during a survey. Resident E reported that room trays were often delivered late, resulting in cold food. Observations on the specified date showed that room trays were delivered after the posted mealtime, with the last tray being delivered at 1:20 p.m., well past the lunch period ending at 1:00 p.m. A temperature check on the last room tray revealed that the cheeseburger was at 106 degrees Fahrenheit, the potato salad at 51 degrees Fahrenheit, and the watermelon at 65 degrees Fahrenheit, all of which were outside the recommended safe temperature ranges. The Dietary Manager confirmed that the hot foods should be served at 120 degrees Fahrenheit and cold foods at 45 degrees Fahrenheit, and indicated that food would be reheated if it did not meet these temperatures. Multiple residents, including Residents C, F, and G, expressed concerns about the food being cold when delivered to their rooms, with Resident F noting that food temperatures were not a concern when dining in the main dining room. These complaints had been discussed in monthly resident council meetings, as confirmed by the Interim Executive Director. The facility's policy on Food and Nutrition Services, as well as a document on safe food handling, outlined the requirements for maintaining appropriate food temperatures, which were not adhered to in this instance. This deficiency was related to a specific complaint, IN00441593.
Failure to Implement Immediate Contact Isolation for Suspected C-Diff Case
Penalty
Summary
The facility failed to place a resident in contact isolation immediately after being tested for Clostridium Difficile (C-Diff), a highly contagious bacteria, while awaiting test results. Resident B, who was under review for antibiotic use, was observed on enhanced barrier precautions instead of the required contact isolation. The resident's clinical record indicated multiple diagnoses, including acute and chronic respiratory failure, type 2 diabetes, stage 3 chronic kidney disease, obstructive sleep apnea, and retention of urine. A nursing progress note documented an episode of foul-smelling, mucus-like bowel movement, prompting the physician to order a stool sample and initiate antibiotic treatment with Flagyl. Despite a physician's order to place the resident in contact isolation every shift until C-Diff was ruled out, Resident B was not isolated for over 24 hours after testing. Enhanced barrier precautions, which do not require personal protective equipment (PPE) every time someone enters the room, were incorrectly used instead of contact isolation, which mandates PPE usage. The Director of Nursing confirmed that residents suspected of having C-Diff should be placed in contact isolation while awaiting laboratory results, as per the facility's current policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Frankfort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wesley Manor Health Center | 1.7 mi | ★★★★★ | 6 | 0 |
| Mulberry Health & Rehabilitation Center | 9.5 mi | ★★★★★ | 0 | 0 |
| Milner Community Health Care | 10.6 mi | ★★★★★ | 6 | 0 |
| Witham Extended Care | 13.6 mi | — | 0 | 0 |
| Homewood Health Campus | 13.8 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.