Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Healthcare Llc - Snf during CMS and state inspections, most recent first.
A resident with a BIMS score of 15 and diagnoses including PE and HTN did not have an Advance Directive available in either the electronic or paper chart. The LPN in Medical Records and the DON both confirmed the document was missing from the chart, despite facility policy requiring it to be determined on admission and available for staff access if needed.
The facility failed to complete a written abuse investigation after a resident’s sister reported suspected physical abuse and said the resident stated someone had pushed her and been mean to her. The DON questioned the resident and completed a body audit with two staff, with no injury found, but did not document the investigation as required by policy. The Administrator knew of the allegation but did not direct staff to complete an incident report, and later stated no further action was needed because the resident could not communicate clearly; the resident had aphasia following cerebral infarction.
A resident’s annual and quarterly MDS assessments were both incorrectly coded as indicating anticoagulant therapy, even though the physician orders did not show any anticoagulant medication. The MDS nurse confirmed the coding error was an oversight, and the DON stated that MDS accuracy is crucial because it informs resident care, interventions, diets, fall risk, and medication plans.
A resident receiving oxygen via nasal cannula had no Oxygen in Use sign posted on or near the room door. An RN confirmed the missing signage and stated a prior sign must have fallen off, and the DON acknowledged that oxygen is highly flammable and that posted signage is necessary for resident and staff safety. The resident had shortness of breath, was cognitively intact, and had an order for oxygen at 2 L via NC every shift.
A CNA provided catheter care to a resident while wearing artificial fingernails about two inches beyond the fingertips, making glove use difficult and requiring multiple glove changes. The CNA used hand sanitizer during glove changes but did not clean underneath the nails. Facility policy stated nails should be kept short and proper hand hygiene performed, and the DON and IP noted long or artificial nails can harbor bacteria and interfere with infection control.
Two residents with pressure ulcers did not receive wound care according to facility policy, as an LPN cleaned their wounds from the outer edge toward the inner aspect instead of from the inner to the outer area. This improper technique, confirmed by the LPN, infection preventionist, and DON, could have led to wound contamination. Both residents had significant medical conditions and physician-ordered wound care regimens.
Staff failed to follow Enhanced Barrier Precautions and proper hand hygiene during wound and incontinent care for two residents. An LPN and CNA did not wear gowns during wound care, and a CNA did not perform hand hygiene between glove changes or don a new gown before providing incontinent care. These actions were not in accordance with facility policy and were acknowledged by staff and nursing leadership.
A resident with contracted hands was unable to use the standard call light in the facility due to her condition. Despite her inability to press the button, the facility did not initially provide an alternative call light, such as a pancake light, which would have allowed her to alert staff by touch. The resident expressed dissatisfaction with the situation, and staff acknowledged the oversight.
A resident's privacy was compromised when a sign indicating aspiration precautions was posted above their bed, visible to anyone entering the room. The resident, with moderate cognitive impairment and dysphagia, was unaware of the sign. The Speech Therapist placed the sign to inform staff about meal positioning, but this action violated the facility's privacy policy. The LPN and Speech Therapist confirmed the breach, and the Administrator acknowledged the failure to respect the resident's privacy.
Two residents with Dysphagia had their enteral feeding pumps improperly operated by CNAs during care, contrary to facility policy requiring only licensed nurses to handle the pumps. The CNAs admitted to turning the pumps off and on, acknowledging their mistake. The DON confirmed that CNAs were trained to leave pump operations to licensed nurses.
A facility failed to discontinue a PRN psychotropic medication for a resident after 14 days, as required by federal guidelines. The resident, with a history of depressive disorders, continued to receive Amitriptyline HCL without a stop date, despite the facility's policy and pharmacist's comments. Interviews with staff confirmed awareness of the guidelines but revealed non-compliance in this case.
Advance Directive Not Available in Resident Chart
Penalty
Summary
The facility failed to have an Advance Directive readily available for staff use for one resident reviewed. The resident was admitted with diagnoses including other pulmonary embolism without acute cor pulmonale and essential hypertension, and the Minimum Data Set showed a BIMS score of 15, indicating the resident was cognitively intact. Review of the resident’s electronic chart and paper chart showed that neither contained an Advance Directive, despite the facility policy stating that the resident’s Advance Directive should be determined on admission and available for staff access if needed. During interview, the LPN in Medical Records confirmed that the Advance Directive was not in the paper chart and stated it should be there so staff can access it if the resident is unable to respond cognitively. The DON also stated that Advance Directives are important because they direct healthcare according to the resident’s wishes, and if they are not addressed, a resident could receive more aggressive care than desired or not receive the care they would have wished for when incapacitated. An observation of the DON reviewing the chart confirmed the Advance Directive was not in the paper chart.
Failure to Document Abuse Investigation After Alleged Physical Abuse
Penalty
Summary
The facility failed to implement its abuse-prevention policy by not completing a written investigation after staff were made aware of a suspected physical abuse allegation involving one resident. The facility’s Abuse Policy required all suspicions or allegations of abuse to be identified and investigated, and its Abuse Investigation Process required a written report from the person reporting the incident, signed witness statements, and documentation describing the resident’s behavior, environment, injuries, and staff observations during the investigation. During an observation and interview, the resident’s sister reported that she found the resident crying and was told that someone had pushed her and had been mean to her. She stated she contacted the DON, who questioned the resident and completed a body audit with two staff members; no injury was found, and an intervention was placed requiring a nurse to be present during care. The DON later confirmed she did not document the investigation and acknowledged the facility policy required a written investigation. The Administrator stated she knew of the allegation but did not instruct staff to complete a written incident report, and later said no further action was necessary because the resident could not communicate clearly. The resident had aphasia following cerebral infarction, and the MDS described mental status as modified independence with some difficulty in new situations only.
Inaccurate MDS Coding for Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one resident reviewed for assessment accuracy. The resident’s annual MDS with an ARD of 7/11/25 and quarterly MDS with an ARD of 10/9/25 were both coded as indicating the resident was receiving anticoagulant therapy, but the physician orders did not show that the resident received any anticoagulant medication. The facility’s MDS Assessment Policy states that it follows the RAI process as set forth by CMS protocol. During interview, the MDS nurse confirmed that she coded both assessments incorrectly and said it was an oversight on her part. The DON stated that the MDS informs the facility of resident needs such as care, interventions, diets, fall risk, and medication plans, and that its accuracy is crucial. The resident was admitted with a diagnosis including unspecified congestive heart failure.
Missing Oxygen Use Signage
Penalty
Summary
The facility failed to ensure oxygen-use cautionary signage was posted on or near the door for Resident #78, who was receiving oxygen via nasal cannula at 2 liters per minute and had a physician’s order for oxygen at 2 liters via nasal cannula every shift. During observation, the resident was lying in bed with oxygen in use, but there was no Oxygen in Use sign posted on or near the room door. RN #1 observed the doorway and confirmed the absence of the required signage, stating that a sign had previously been present and must have fallen off. The DON later confirmed that oxygen is a highly flammable gas and that signage identifying oxygen use is necessary for resident and staff safety. The resident was admitted with shortness of breath, had a BIMS score of 15, and was cognitively intact, with oxygen therapy documented in the 14-day lookback period.
Infection Control Failure During Catheter Care
Penalty
Summary
The facility failed to follow infection control guidelines during catheter care for one resident when a CNA provided care while wearing artificial fingernails that extended approximately two inches beyond the fingertips. During the observation, the CNA had difficulty placing gloves over the long nails and required four glove changes during the procedure. Each time the gloves were changed, she used hand sanitizer but did not clean underneath the long artificial nails. The facility’s Hand Hygiene policy dated 7/1/24 stated that all staff will perform proper hand hygiene procedures to prevent the spread of infection, and the Dress Code policy stated that long nails should not be worn and fingernails should be no longer than the tip of the finger. During interview, the CNA acknowledged that her fingernails were fake and very long, and stated they caused difficulty when putting on gloves during care. The DON and Infection Preventionist both stated that staff nails should be kept neatly trimmed or no longer than the fingertip because long or artificial nails can harbor bacteria and are difficult to clean under. The resident involved was admitted with encephalopathy and had a BIMS score of 15, indicating cognitive intactness.
Improper Wound Care Technique Leading to Potential Wound Contamination
Penalty
Summary
The facility failed to provide wound care in a manner that would prevent the possibility of wound infection for two residents with pressure ulcers. During wound care observations, an LPN cleaned the wound beds of both residents from the outer edge toward the inner aspect in a circular motion, rather than from the inner aspect outward as required by facility policy and standard infection control practices. This method of cleaning was repeated multiple times for each resident, and the LPN then dried the wound sites using the same incorrect technique before applying clean dressings. The LPN later confirmed in an interview that she did not clean the wounds correctly and acknowledged that her actions could lead to wound contamination and infection. Resident #1 had a stage IV pressure injury to the sacrum and diagnoses including heart failure and type 2 diabetes mellitus with hyperglycemia, with a moderate cognitive impairment. Resident #4 had a stage 3 pressure ulcer of the sacral region and diagnoses of essential hypertension and type 2 diabetes mellitus, and was unable to complete a cognitive interview. Both residents had physician orders for specific wound care regimens. The facility's infection preventionist and DON confirmed that the wounds were not cleaned according to policy, and that the improper technique could result in contamination of the wounds.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during wound care and incontinent care for two residents. During wound care for a resident with a stage IV pressure injury, both the LPN and CNA assisting did not wear gowns as required by the facility's Enhanced Barrier Precautions (EBP) policy. Both staff members acknowledged forgetting to don gowns, despite having received prior training on EBP. The facility's policy specifies that gowns and gloves must be used during high-contact care activities to prevent the transmission of multidrug-resistant organisms. In a separate incident, a CNA providing incontinent care to another resident did not perform hand hygiene between glove changes and used soiled gloves to handle clean supplies. The CNA also failed to don a new gown or wash hands before starting care after removing a previously used gown in the hallway. Both the Infection Prevention Nurse and the Director of Nursing confirmed that the staff did not follow required infection control protocols, including proper gown use and hand hygiene, placing residents at risk for infection.
Failure to Provide Appropriate Call Light for Resident with Contracted Hands
Penalty
Summary
The facility failed to accommodate the needs of a resident with contracted hands by not providing an appropriate call light system. The resident, who was admitted with diagnoses including contracture of the left upper arm and hand, was unable to use the standard call light due to her condition. Despite her inability to press the button on the standard call light, the facility did not initially provide an alternative solution, such as a pancake light, which would have allowed her to alert staff by touch. The deficiency was identified through observations and interviews with the resident and staff. The resident expressed difficulty in getting staff attention and dissatisfaction with the situation, as she had to rely on calling out for help. The CNA acknowledged the resident's inability to use the call light and mentioned that rounds were conducted every two hours. The DON confirmed the resident's condition and the oversight in not providing a suitable call light, which was determined at the time of admission.
Violation of Resident Privacy Due to Visible Medical Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's medical information by posting a sign above the bed of a resident, indicating aspiration precautions. This sign was visible to anyone entering the room, which violated the resident's right to privacy. The resident, who had a diagnosis of dysphagia and a moderate cognitive impairment, was unaware of the sign's presence. The sign was placed by the Speech Therapist to inform staff about the necessary positioning of the resident during meals. During interviews, both the Licensed Practical Nurse and the Speech Therapist confirmed the presence of the sign and acknowledged the breach of privacy. The Speech Therapist admitted to placing the sign after educating the staff on the resident's care needs. The facility's Administrator and Director of Nursing were informed of the situation and confirmed that the posting of such information did not respect the resident's privacy and dignity, as required by the facility's policy on Resident's Rights.
Improper Operation of Enteral Feeding Pumps by CNAs
Penalty
Summary
The facility failed to ensure that enteral feeding pumps were operated exclusively by licensed nursing staff, as required by their policy. During an observation, a Certified Nurse Aide (CNA) turned off and then back on the enteral feeding pump for a resident while providing incontinent care. The CNA later confirmed in an interview that she was aware that only licensed nurses should operate the feeding pumps but acted out of nervousness and without thinking. The resident involved had been admitted with a diagnosis of Dysphagia. In another instance, two CNAs were observed providing care to a resident when the enteral feeding pump began beeping. One CNA instructed the other to press the hold button to stop the beeping, and the CNA complied, later restarting the feeding pump after care was completed. The CNA admitted in an interview that she should not have operated the feeding pump and acknowledged that it was the responsibility of the licensed nurse. The Director of Nursing confirmed that CNAs had been trained that only licensed nurses should operate the feeding pumps. The resident involved also had a diagnosis of Dysphagia.
Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary medication by continuing a PRN psychotropic medication past a 14-day duration. The facility's policy on monitoring antipsychotic medication therapy, revised in June 2015, requires the pharmacy consultant to review medications monthly and make dose reduction recommendations as per CMS guidelines. However, a review of the Order Summary Report revealed that a resident had a physician's order for Amitriptyline HCL, a psychotropic medication, without a stop date, and the medication was continued beyond the 14-day limit without a new order. The resident, admitted in January 2017 with a diagnosis of Other Recurrent Depressive Disorders, was noted to be taking an antidepressant according to the Quarterly MDS. Despite the pharmacist's comments on the need for a 14-day stop order and physician evaluation before continuation, the Interdisciplinary Team deemed the current medication regime appropriate. Interviews with the Nurse Practitioner and the facility's Administrator and DON confirmed awareness of the federal guidelines but indicated a failure to adhere to them in this instance.
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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 Clinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodlands Rehabilitation And Healthcare Center | 2.3 mi | ★★★★★ | 12 | 0 |
| Magnolia Senior Care, Llc | 4.9 mi | ★★★★★ | 5 | 0 |
| Chadwick Community Care Center | 6 mi | ★★★★★ | 11 | 0 |
| Pleasant Hills Community Living Center | 6.4 mi | ★★★★★ | 2 | 1 |
| Pine Forest Health And Rehabilitation | 7.6 mi | ★★★★★ | 6 | 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.