Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Several residents did not receive showers according to their preferences or scheduled frequency, with some going over a week or more without a shower. Care plans lacked documentation of shower preferences, and staff interviews confirmed inadequate staffing, with only one shower aide available and not present on the day of the survey. Residents expressed discomfort and embarrassment due to missed showers, and staff acknowledged that most residents were not receiving the expected number of showers per week.
A resident with multiple medical conditions requiring pain management experienced a loss of morphine sulfate ER tablets when staff failed to accurately complete and reconcile narcotic counts during shift changes. The required procedures for handling and documenting controlled substances were not consistently followed, resulting in 30 tablets going missing and the medication not being accounted for while in the facility's possession.
A resident was administered excessive doses of apixaban and diltiazem for several days due to incorrect transcription of hospital discharge medication orders. Despite a system warning about the high dosage, staff did not notify the physician or document the error, and the discrepancy was not addressed until identified by the pharmacy consultant. The resident, who had multiple complex medical conditions, died on the day the medication error was discovered. Staff interviews revealed confusion about order entry and verification processes, and the medication errors went unrecognized by most staff until after the incident.
The facility did not have a written transfer agreement with a Medicare or Medicaid-certified hospital, as required, and staff were unaware of this federal requirement. No policy or documentation regarding hospital transfers was available, and the deficiency was confirmed through record review and staff interviews.
The facility did not honor the shower preferences of four residents, failing to provide showers according to their stated schedules and preferences. Despite policy requirements, care plans often lacked documentation of shower needs or preferences, and staff interviews confirmed that residents were not receiving showers twice per week due to a shortage of shower aides. Residents expressed feeling dirty and embarrassed, and there was no documentation of shower refusals to account for missed showers.
A resident with multiple medical conditions requiring pain management experienced a loss of morphine sulfate ER tablets when 30 tablets went missing from the facility's medication cart. Despite policies requiring accurate shift-to-shift narcotic counts and immediate reporting of discrepancies, staff failed to follow procedures, leading to the unaccounted loss of controlled medication.
A resident admitted for post-joint replacement care with osteoarthritis and osteoporosis had a hospital discharge order for alendronate 70 mg weekly, but staff incorrectly entered the order as a daily dose. A system alert flagged the error, but there was no documentation that it was addressed, and the medication was not available for two days. Staff interviews revealed lapses in order verification and delayed chart audits, with recent turnover in the DON role contributing to oversight issues.
The facility failed to properly screen staff for TB, with lapses in completing the two-step tuberculin skin test (TST) before resident contact. An RN lacked a documented second step or prior testing history, a CMT's test was read prematurely, and an LPN's test was delayed. Interviews revealed inconsistencies in TB testing protocols, contributing to the deficiency.
The facility failed to document a full investigation, final decision, or follow-up for grievances filed by residents against a CNA for rough and rude behavior. Despite multiple complaints, the facility only provided verbal education to the CNA without proper documentation, indicating a systemic failure in the grievance process.
The facility failed to develop and implement complete care plans for several residents, omitting critical information related to psychotropic medication use and specific diagnoses. A resident with anxiety and depressive disorders was not care planned for their medication use, while another with multiple mental health diagnoses also lacked a medication-related care plan. Additional residents had care plans that did not address significant medical conditions or medication use, as confirmed by the DON.
The facility failed to provide effective pain management for four residents by not ensuring that pain medication was available as ordered. A resident with fibromyalgia did not receive scheduled doses of tramadol and acetaminophen, leading to increased pain. Another resident with chronic pain missed several doses of tramadol without documentation of physician notification or alternative interventions. A third resident with chronic pain syndrome missed doses of Norco, and a fourth resident with frequent pain missed doses of hydrocodone-acetaminophen. Staff interviews revealed a lack of clear procedures for reordering medications and utilizing backup pharmacies.
The facility failed to ensure proper documentation of narcotic counts at shift changes, as evidenced by missing signatures in Narcotic Record Books across multiple halls and shifts. Interviews confirmed that staff were not consistently signing off after narcotic counts, indicating a lack of adherence to required procedures for controlled drug reconciliation.
The facility failed to monitor side effects and behaviors in residents receiving psychotropic medications, as required by their policy. This deficiency was identified through interviews and record reviews for multiple residents, revealing a lack of documentation for monitoring side effects or specific behaviors associated with these medications. Nursing staff confirmed the absence of behavior monitoring on the MAR/TAR, indicating a systemic issue.
A facility failed to provide a written transfer notice to a resident or their representative during an emergent hospital transfer. The resident, admitted with chronic respiratory failure, was sent to the ER for increased anxiety, back pain, and breathing difficulties, and later admitted to the ICU for COPD. Staff interviews confirmed that a transfer/discharge summary was not completed or provided, contrary to the facility's policy.
The facility failed to update PASARR Level I assessments for two residents after new mental illness diagnoses. One resident had a new diagnosis of mood disorder and was prescribed olanzapine, while another was diagnosed with bipolar disorder following a suicide attempt. Staff interviews revealed a lack of understanding and training regarding the need for updated PASARR assessments.
The facility did not create a baseline care plan for a resident with schizophrenia within 48 hours of admission, as required by policy. The resident's medical record lacked documentation of a care plan addressing the schizophrenia diagnosis. Interviews with the DON and Administrator confirmed the omission.
A facility failed to change a resident's nebulizer tubing weekly as ordered, leading to a deficiency in respiratory care. The resident, with COPD, asthma, and allergic rhinitis, had an order for tubing changes every Sunday night. Observations showed undated tubing, and staff did not sign off on the tubing change for the specified date. An RN confirmed the tubing should have been dated and changed weekly.
A facility failed to ensure proper dialysis communication for a resident with ESRD, who required hemodialysis three times a week. The resident's Dialysis Communication Record was inconsistently completed over several months, despite the care plan's requirement for coordination with the dialysis team. Staff interviews revealed that the communication lapses began after a change in the resident's dialysis schedule, and the issue was not reported or addressed by the staff.
Failure to Honor Resident Shower Preferences and Promote Self-Determination
Penalty
Summary
The facility failed to promote and facilitate residents' rights to self-determination by not honoring the shower preferences of four residents. Despite facility policy requiring documentation of showers, refusals, and resident preferences, multiple residents did not receive showers according to their stated schedules or preferences. For example, one resident, who was cognitively intact and totally dependent on staff for bathing, reported that their last shower was over a week ago, and prior to that, it had been over two weeks, despite a preference for two showers per week. Another resident, with moderate cognitive impairment and a need for assistance with personal care, stated they had not received a shower in over two weeks and declined a shower previously because it was to be provided by a male staff member, which was not their preference. Care plan reviews for these residents revealed that staff did not document or plan for shower assistance or individual shower preferences. Shower records showed significant gaps between showers, with some residents going up to thirteen days without a shower and no documentation of refusals. Residents expressed feeling dirty, uncomfortable, and embarrassed due to the lack of regular showers, and one resident specifically noted embarrassment about attending a doctor's appointment without having been showered. Interviews with staff, including CNAs, LPNs, the ADON, and the DON, confirmed that there was only one shower aide for the entire facility, and on the day of the survey, no shower aide was present. Staff acknowledged that very few residents were receiving two showers per week as expected, and the lack of available shower aides was cited as the primary reason. The facility's failure to provide adequate staffing and to follow residents' shower preferences directly resulted in the deficiency.
Failure to Protect Resident from Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property when narcotic pain medication, specifically morphine sulfate ER 30 mg tablets, went missing while in the possession of facility staff. The resident involved had a history of rhabdomyolysis, multiple rib fractures, pain, muscle weakness, and osteoarthritis, and was receiving morphine sulfate ER as ordered by the physician for pain management. The medication administration record indicated that the resident was to receive the medication twice daily, and pharmacy delivery records confirmed the supply of tablets provided to the facility. According to the controlled medication logbook, a significant discrepancy was identified during a shift change, where 30 tablets of morphine sulfate were found to be missing. Staff statements and interviews revealed that the narcotic count was not accurately completed during the shift change, with one LPN admitting to rushing through the count and being unsure if it was correct. The facility's policy required that controlled substances be counted and reconciled by two nurses at each change of custody, with any discrepancies reported immediately to the charge nurse and DON. However, the required procedures were not consistently followed, leading to the unaccounted loss of medication. Interviews with nursing staff and facility leadership confirmed that the expected process for handling and counting controlled substances was not adhered to at all times. The missing medication was not located despite a search of the medication cart and room, and staff were unable to account for the discrepancy. The failure to accurately count and secure the controlled medication resulted in the resident's narcotic pain medication being unaccounted for while under the facility's care.
Significant Medication Errors Due to Incorrect Transcription of Admission Orders
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors when staff did not correctly transcribe new admission medication orders for a resident. Specifically, staff entered and administered apixaban (Eliquis) at 5 mg twice daily and diltiazem ER at 360 mg twice daily, which were both in excess of the dosages ordered on the resident's hospital discharge summary. The hospital discharge summary specified apixaban 5 mg, take one-half tablet twice daily, and diltiazem ER 120 mg once daily. The incorrect dosages were administered for five days. Despite a system-generated warning about the excessive diltiazem dosage, staff did not document any follow-up or notification to the physician regarding the warning or the medication error. The discrepancy between the discharge orders, the orders entered, and the physician's note was not addressed by staff. The pharmacy consultant identified the medication errors during a monthly drug regimen review and notified facility staff, but prior to this, there was no documentation of physician or family notification about the errors. The resident involved had multiple diagnoses, including acute respiratory failure with hypoxia, influenza A, congestive heart failure, type 2 diabetes mellitus, and COPD. The resident was alert, cognitively intact, and had a goal to return to the community. The resident passed away on the day the medication error was discovered. Interviews with staff revealed a lack of clarity regarding the process for order entry, verification, and chart audits, and several staff members were unaware of the medication errors until after the fact.
Lack of Written Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with at least one Medicare or Medicaid-certified hospital to ensure residents could be transferred promptly when in need of medical care. Record review revealed the absence of both a policy and a written agreement regarding hospital transfers. During interviews, the Regional Director of Operations and the Regional Nurse Consultant both stated they were unaware of the federal requirement for such an agreement, and staff were unable to locate any documentation of a transfer agreement. The Administrator also confirmed the inability to find a written agreement with a hospital. This deficiency had the potential to affect all 74 residents in the facility's census. No specific residents or medical conditions were detailed in the report, and the deficiency was identified through record review and staff interviews.
Failure to Honor Resident Shower Preferences and Promote Self-Determination
Penalty
Summary
The facility failed to promote and facilitate residents' rights to self-determination by not honoring the shower preferences of four residents. Despite facility policy requiring documentation of showers, refusals, and resident preferences, records showed that residents did not consistently receive showers according to their stated preferences or the facility's expected schedule. For example, one resident, who was cognitively intact and totally dependent on staff for bathing, reported that their last shower was over a week ago, and prior to that, it had been over two weeks, despite a preference for two showers per week. Another resident, with moderate cognitive impairment and a need for assistance with personal care, reported not receiving a shower for over two weeks and expressed discomfort with being offered a shower by a male staff member, which was not accommodated. Care plan reviews revealed that staff did not consistently document or plan for residents' shower assistance needs or preferences. Several residents' care plans lacked any mention of shower preferences or required assistance, even though their medical conditions, such as multiple sclerosis, hemiplegia, chronic pain, and muscle weakness, necessitated significant staff support for bathing. Shower documentation sheets indicated gaps of up to thirteen days between showers for some residents, and there were no records of shower refusals to explain these gaps. Residents expressed feeling dirty, uncomfortable, and embarrassed due to the infrequency of showers, especially when attending medical appointments. Interviews with staff, including CNAs, LPNs, the ADON, and the DON, confirmed that residents were not receiving showers twice per week as expected. Staff attributed this to a shortage of shower aides, with only one full-time shower aide available, who was not working on the day of the survey. Floor aides were not consistently assigned to provide showers, and there was a lack of communication regarding which residents needed showers. The DON acknowledged the expectation for two showers per week and the requirement for residents to sign if they refused, but records did not reflect refusals, indicating a failure to meet both policy and resident preferences.
Failure to Protect Resident from Misappropriation of Narcotic Medication
Penalty
Summary
Facility staff failed to protect a resident's right to be free from misappropriation of property when narcotic pain medication, specifically morphine sulfate ER 30 mg tablets, went missing while in the facility's possession. The resident involved had a history of rhabdomyolysis, multiple rib fractures, pain, muscle weakness, and osteoarthritis, and was receiving morphine sulfate ER as ordered by the physician for pain management. The medication administration record showed consistent administration of the medication, and pharmacy delivery records confirmed the quantities received by the facility. On a specific date, staff documented a significant discrepancy in the controlled medication logbook, noting that 30 tablets of morphine sulfate were missing from the medication cart. The count had been correct during previous shift changes, but during one shift, the count dropped from 57 to 27 tablets without explanation. Staff statements indicated uncertainty and rushing during the medication count, and the missing medication was not located after a search of the medication cart and medication room. Interviews with nursing staff and facility leadership confirmed that the facility's policy required accurate narcotic counts at each shift change, with immediate notification to management if discrepancies were found. Despite these policies, the required procedures were not followed, resulting in the loss of controlled medication while under the facility's control.
Failure to Accurately Transcribe and Verify Physician Orders on Admission
Penalty
Summary
Facility staff failed to provide care that met professional standards of quality for one resident by not accurately transcribing the resident's physician orders upon admission. The resident, who had diagnoses including aftercare following joint replacement surgery, osteoarthritis of the left knee, and osteoporosis, was admitted with a hospital discharge order for alendronate 70 mg to be given once weekly. However, the physician order was incorrectly entered into the facility's system as a daily dose, which exceeded the recommended dosing regimen. A system alert was generated indicating that the entered dosing regimen was outside the recommended frequency, but there was no documentation that staff addressed this alert. Additionally, the medication was not available for administration on two consecutive days, as documented in the Medication Administration Record (MAR), and the order was later corrected to the appropriate weekly dosing. Interviews with staff revealed that the process for entering and verifying new admission orders involved multiple steps, including review by the charge nurse, physician approval, and pharmacy notification, but there were lapses in following these procedures and in conducting timely chart audits. Staff interviews also indicated that chart audits had fallen behind, and there was a lack of clarity regarding who was responsible for verifying the accuracy of order entry. The facility had experienced turnover in the Director of Nursing position, which may have contributed to inconsistencies in oversight. The failure to accurately transcribe and verify physician orders resulted in a deviation from professional standards of medication administration for the resident.
Inadequate TB Screening for Staff
Penalty
Summary
The facility failed to maintain an effective infection control program by not properly screening staff for tuberculosis (TB) as required. Specifically, the facility did not ensure that the first and second steps of the two-step tuberculin skin test (TST) were completed before staff had contact with residents. This deficiency was observed in three staff members: a Registered Nurse (RN), a Certified Medication Tech (CMT), and a Licensed Practical Nurse (LPN). The RN did not have a documented second step TB test or a prior history of testing within the last two years. The CMT's first step TB test was read only 24 hours after administration, and the LPN's first step TB test was administered and read over a month after their hire date, with no documentation of prior testing. Interviews with staff, including LPNs, the Director of Nursing (DON), and the Regional Nurse Consultant (RNC), revealed inconsistencies in the understanding and implementation of TB testing protocols. The staff indicated that TB tests should be read 48 to 72 hours after placement, but there were discrepancies in the timing and documentation of these tests. The facility's policy required TB testing to be completed before staff could work with residents, yet the reviewed records showed lapses in adherence to this policy, contributing to the deficiency in infection control practices.
Inadequate Grievance Process Documentation
Penalty
Summary
The facility failed to implement an effective grievance process, as evidenced by multiple instances where grievances filed by residents were not fully investigated or documented. The facility's policy on grievances requires a comprehensive investigation and documentation of the circumstances, witness accounts, and recommendations for corrective action. However, in several cases involving a Certified Nurse Aide (CNA) identified as CNA 4, the facility did not adhere to these requirements. Residents reported that CNA 4 was rough during care and transfers, and exhibited rude behavior. Despite these complaints, the facility's staff only provided verbal education to CNA 4 without documenting a full investigation, final decision, or follow-up with the residents who filed the grievances. The grievance reports reviewed from April to August 2024 consistently showed a lack of thorough documentation and follow-up. In each instance, the staff's response was limited to verbal education of CNA 4, with no written record of a comprehensive investigation or resolution. During an interview, the Administrator acknowledged that the education provided was not documented, and the Regional Nurse Consultant agreed that the existing documentation was insufficient to ensure grievance resolution. This pattern of inadequate documentation and follow-up indicates a systemic failure in the facility's grievance process, as outlined in their policy.
Incomplete Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement complete and accurate care plans for five residents, as observed during a survey. Resident #36, who was admitted with anxiety disorder and major depressive disorder, was receiving psychotropic medications, including buspirone and quetiapine. However, the care plan did not address the use of these medications. The MDS Coordinator/Director of Nursing acknowledged that the medications should have been included in the care plan. Resident #42, diagnosed with major depressive disorder, generalized anxiety disorder, panic disorder, bipolar II disorder, alcohol abuse, and opioid dependence, was also receiving psychotropic medication, specifically fluoxetine. Similar to Resident #36, the care plan for Resident #42 did not include interventions related to the medication use. The MDS Coordinator/Director of Nursing confirmed this oversight during an interview. Additional deficiencies were noted for Resident #3, who had major depressive disorder, anxiety disorder, and Alzheimer's Disease, and was receiving citalopram and olanzapine. The care plan did not address these diagnoses or the use of antidepressants. Resident #1's care plan failed to address chronic allergic conjunctivitis and a left wrist contracture resulting from a stroke. Lastly, Resident #4's care plan did not include considerations for hearing and vision impairments or the use of anti-anxiety and anti-depressant medications. The Director of Nursing confirmed these omissions during interviews.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for four residents by not ensuring that pain medication was available as ordered. Resident #57, who was admitted with diagnoses including pain and fibromyalgia, did not receive scheduled doses of tramadol and acetaminophen on multiple occasions. Despite the resident rating their pain as high as seven or eight out of ten, the facility did not have the medication available, and there was a delay in communication with the physician and pharmacy to resolve the issue. The resident reported increased pain due to the lack of tramadol. Resident #32, who was severely cognitively impaired and had chronic pain, also missed several doses of tramadol. The facility's records did not show any documentation of physician notification or attempts at non-pharmacological interventions. Similarly, Resident #18, with chronic pain syndrome, missed multiple doses of Norco, and there was no documentation of physician notification or alternative pain management strategies being attempted. Resident #7, who was moderately cognitively impaired and experienced frequent pain, missed several doses of hydrocodone-acetaminophen. The facility staff failed to notify the physician or attempt non-pharmacological interventions. Interviews with facility staff revealed a lack of clear procedures for reordering medications and utilizing backup pharmacies, contributing to the residents' unmet pain management needs.
Failure to Document Narcotic Counts at Shift Changes
Penalty
Summary
The facility failed to ensure a system was in place to account for all controlled drugs, as evidenced by missing signatures in the Narcotic Record Books across multiple halls and shifts. The review of the 200 Hall Narcotic Record Books, conducted with an LPN and Medical Records, revealed missing signatures for several dates and times, indicating that the narcotic count was not consistently documented at each change of shift. Similar issues were found in the 100 Hall Narcotic Record Books, where both medication techs and nurses failed to sign off on narcotic counts at various times, further demonstrating a lack of adherence to the required procedures. During interviews, both an RN and the Administrator confirmed the presence of empty signature areas in the Narcotic Record Books, acknowledging that staff were not consistently signing at every change of shift after the narcotic count was completed. This lack of documentation suggests that the facility did not have a reliable system in place to ensure accurate reconciliation of controlled drugs, as required by regulations. The failure to document narcotic counts properly could lead to discrepancies in drug accountability and potential risks to resident safety.
Failure to Monitor Psychotropic Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to implement a system for monitoring side effects and targeted behaviors in residents receiving psychotropic medications. This deficiency was identified through interviews and record reviews for five residents who were administered psychotropic medications without adequate documentation of monitoring for side effects or specific behaviors. The facility's policy on psychotropic medication use, dated July 2022, mandates monitoring for efficacy and adverse consequences, but this was not adhered to in practice. Resident #48, who has severe cognitive impairment and multiple mental health diagnoses, was receiving antipsychotic medications fluphenazine and risperidone. However, there was no documentation of monitoring for side effects or behaviors associated with these medications in the resident's Medication Administration Record (MAR) or Progress Notes. Similarly, Resident #36, with no cognitive impairment but diagnosed with anxiety and major depressive disorders, was on buspirone and quetiapine. Again, there was a lack of documentation for monitoring side effects or behaviors. The issue extended to other residents, including Resident #42, who was on fluoxetine for depression and anxiety, and Resident #4, who was prescribed lorazepam and paroxetine for anxiety and depression. Both residents' records lacked documentation of monitoring for side effects or behaviors. Interviews with nursing staff, including a Registered Nurse (RN) and the Director of Nursing (DON), confirmed the absence of behavior monitoring on the MAR/TAR, indicating a systemic failure to ensure consistent monitoring across the facility.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide timely written notice of transfer or discharge to a resident or their representative, as required by regulations. This deficiency was identified during a review of the facility's practices concerning emergent hospital transfers. Specifically, Resident #56, who was admitted with chronic respiratory failure and hypoxia, was transferred to the emergency room due to increased anxiety, extreme back pain, and difficulty breathing. The resident was subsequently admitted to the ICU for chronic obstructive pulmonary disease. However, the facility did not document or provide a written transfer notice to the resident or their representative. Interviews with staff, including an LPN and the Administrator, confirmed that a transfer/discharge summary was not completed or provided in this case, which is contrary to the facility's discharge policy.
Failure to Update PASARR Level I Assessments for New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that a new Preadmission Screening and Resident Review (PASARR) Level I assessment was submitted after new mental illness diagnoses for two residents. Resident #20 was admitted with diagnoses including unspecified mood affective disorder and major depressive disorder. However, the PASARR Level I assessment dated 05/14/20 did not reflect any mental illness diagnosis. Despite the resident's care plan indicating verbal aggression and a new diagnosis of mood disorder following a psychiatric evaluation, no new PASARR Level I was completed. Additionally, the resident was prescribed olanzapine for a psychotic disorder, yet staff did not document a new PASARR Level I assessment. Similarly, Resident #42 was admitted with multiple diagnoses, including major depressive disorder and bipolar II disorder. The PASARR Level I assessment dated 08/30/20 did not include any mental illness diagnosis. Following a psychiatric follow-up, the resident was diagnosed with bipolar disorder and reported a suicide attempt. Despite these significant changes, no new PASARR Level I assessment was completed. Interviews with staff revealed a lack of understanding and training regarding the need for updated PASARR assessments following new psychiatric diagnoses.
Failure to Develop Baseline Care Plan for Schizophrenia Diagnosis
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident diagnosed with schizophrenia within 48 hours of admission, as required by their policy. The resident's face sheet in the electronic medical record indicated an admission date and a diagnosis of schizophrenia. However, a review of the medical record revealed that staff did not document or have a copy of a baseline or comprehensive care plan addressing the resident's schizophrenia diagnosis within the specified timeframe. Interviews with the Director of Nursing and the Administrator confirmed that the baseline care plan should have included the resident's diagnosis of schizophrenia, but it was not included.
Failure to Change Nebulizer Tubing as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident diagnosed with COPD, asthma, and allergic rhinitis. The resident's care plan included an order for nebulizer tubing to be changed weekly, specifically every Sunday night, and to be placed in a bag when not in use. However, a review of the Treatment Administration Record for September 2024 revealed that staff did not sign off on completing the order on the night of September 1, 2024, which was a Sunday. Observations on September 2 and 3, 2024, showed that the resident's nebulizer machine was in her room with undated tubing, indicating that the tubing had not been changed as ordered. During an interview, RN #1 confirmed that the nebulizer tubing should have been dated to indicate when it was last changed and acknowledged that the tubing was supposed to be changed every Sunday night. This oversight in following the physician's order led to a deficiency in the resident's respiratory care.
Failure in Dialysis Communication for Resident with ESRD
Penalty
Summary
The facility failed to provide dialysis services per standards of practice and the resident's care plan for a resident with end-stage renal disease (ESRD) who required hemodialysis. The resident, who had severe cognitive impairment, was scheduled for dialysis three times a week. However, the facility did not maintain ongoing pre and post-dialysis communication as required. The Dialysis Communication Record was only completed on a few occasions over a three-month period, despite the care plan's directive to coordinate with the dialysis team. Interviews with facility staff revealed that the communication lapses occurred after the resident's dialysis time was changed to 5:00 A.M. The night shift was responsible for sending the communication form with the resident, and the day shift was to ensure it returned completed. However, this process was not consistently followed, and staff did not report the issue or take corrective action. The Director of Nursing confirmed that the communication form should have been completed and returned with the resident each time, and staff should have contacted the dialysis center if the form was not filled out.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 37 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Adair Village | 1.7 mi | ★★★★★ | 12 | 0 |
| Truman Lake Manor Inc | 16 mi | ★★★★★ | 7 | 0 |
| Windsor Healthcare & Rehab Center | 17.2 mi | ★★★★★ | 0 | 0 |
| Appleton City Manor | 18.6 mi | ★★★★★ | 2 | 1 |
| Aspire Senior Living Warsaw | 22.4 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Clinton Healthcare And Rehabilitation Center.
100% money-back within 48 hours.
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.