Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clinton Therapy & Living Center during CMS and state inspections, most recent first.
The facility did not provide a SNF ABN to two residents who were discharged from skilled services but continued to reside in the facility, even though they had Medicare benefit days remaining. The administrator stated she was unaware of the need to issue the ABN in these circumstances.
The facility did not submit MDS assessment data to CMS within the required timeframe for four residents. Assessments were completed but not transmitted within the mandated period, and the DON confirmed these submissions were late according to CMS guidelines.
A resident prescribed levothyroxine for hypothyroidism did not consistently receive the medication as ordered, with multiple missed doses recorded over several months. Facility staff confirmed that blanks on the medication administration record indicated the medication was not given, and there was no documentation explaining the omissions, contrary to facility policy.
Two residents had inaccuracies in their MDS assessments: one had an annual assessment with unassessed pain and functional status despite being on routine pain management, and another had a quarterly assessment that failed to document ongoing hospice services, even though a physician order confirmed hospice admission. The DON acknowledged both assessment errors.
A resident with end stage COPD was receiving continuous oxygen therapy without a current physician order. Documentation showed the resident was on 4L/min oxygen with an oxygen saturation of 88%, but the only order for oxygen had been discontinued months earlier. The DON confirmed there were no active orders for the ongoing oxygen use.
A resident with neuromuscular bladder dysfunction and alcoholic cirrhosis was found with an indwelling catheter in place, but no physician's order for the catheter was present in the medical record. The DON confirmed that an order should have been obtained.
A multidose vial of Tuberculin PPD was found opened and not dated in the medication storage room. The ADON confirmed that the vial should have been dated when opened. This occurred in a facility with 28 residents.
A resident with dementia and a history of wandering was repeatedly identified as high risk for elopement, but the care plan was not updated to address these behaviors until after the resident left the facility twice, once being found a significant distance away on a busy road. Staff awareness and training on the resident's risk were inconsistent, and exit door alarms were reported as malfunctioning or not heard during the incident, resulting in inadequate supervision and interventions.
A resident with dementia and other cognitive impairments, identified as high risk for wandering and elopement, did not have a care plan updated to address these risks despite repeated incidents and assessments indicating ongoing danger. The care plan only included diversionary activities and was not revised to include appropriate interventions until months after the resident's admission, with staff confirming the lack of timely updates.
The facility failed to report abuse allegations to the OSDH within the required timeframe for three residents. A resident with intact cognition experienced repeated incidents of another resident entering their room naked, which was not reported as sexual abuse until prompted. Another resident alleged physical abuse by staff, but the facility delayed reporting to OSDH and suspending the accused staff due to staffing issues.
A resident with intact cognition reported frequent incidents of another resident with cognitive impairment entering their room naked and taking belongings. Despite staff awareness and reports to the administrator, the facility failed to investigate these incidents as potential abuse, only reporting them as misappropriation after prompting by the survey agency.
The facility failed to submit MDS assessments for two residents within the required timeframe. The assessments, completed on a specific date, were submitted late, exceeding the 14-day period allowed by CMS guidelines. The MDS coordinator confirmed the delay during an interview.
The facility did not monitor or log dish machine temperatures, sanitizer concentration, and refrigeration temperatures as required by policy. The dietary manager admitted to not performing these tasks, which are essential for safe food handling and storage.
A facility failed to inform a resident and/or their legal representative in writing about the treatments and side effects of psychotropic medications. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed several psychotropic medications, but their EHR lacked documentation of consents, education, and alternative treatments. The DON admitted to not completing these necessary steps.
The facility failed to maintain a safe and comfortable environment, with temperatures in common areas and resident rooms below the required range, causing residents to wear coats and use blankets for warmth. Additionally, a damaged wall with a sharp metal strip posed a safety risk, as acknowledged by staff, including the maintenance supervisor and DON.
A resident with intact cognition was repeatedly subjected to inappropriate behavior by another resident with impaired cognition, who frequently entered their room naked. Despite staff awareness and documentation of these incidents, the behavior persisted, indicating a failure to prevent sexual abuse as per the facility's policy.
The facility failed to implement its abuse policy, as evidenced by two incidents involving residents. One resident was repeatedly subjected to another entering their room naked and attempting to take personal items, with no immediate action taken to prevent further occurrences. In another case, a resident alleged physical abuse by staff, but the facility did not report the incident promptly or suspend the accused staff immediately. These incidents highlight deficiencies in the facility's handling of abuse allegations.
A facility failed to include hospice services in the care plan for a resident with senile degeneration of the brain and dementia, despite having a physician order for hospice. The facility's policy required care plans to be complete and current, but the MDS Coordinator confirmed that hospice services were not added to the resident's care plan as required.
A resident with multiple diagnoses did not receive their prescribed clonidine due to a failure in reordering the medication. The facility's policy requires medications to be reordered three days before the last dose, but there was no documentation of this being done. The CMA responsible did not reorder the medication, and the DON was not informed of the shortage until it was identified during a survey.
A resident with dementia and bipolar disorder continued to receive incorrect dosages of Risperdal and Zyprexa despite a physician's order to adjust the medications. The facility's policy required the nurse or DON to input new orders into the system, but this was not done, resulting in the resident receiving the wrong medication regimen.
A resident with dementia and a history of elopement was inadequately supervised, leading to multiple elopement incidents. Despite being identified as an elopement risk, the care plan was not promptly updated after the first incident. The resident managed to leave the facility twice, once crossing a railroad track and a freeway. The facility failed to involve the IDT in decision-making, and monitoring documentation was inconsistent.
A resident with dementia and other mental health disorders was identified as an elopement risk, but the facility failed to update their care plan after multiple elopement incidents. Despite assessments indicating high risk, the care plan lacked additional interventions, and the DON was unaware of previous elopements, leading to inadequate monitoring and protection.
A resident with Alzheimer's and dementia eloped from the facility multiple times due to inadequate supervision and incomplete documentation. Despite being on 1:1 supervision, the resident left the facility without staff knowledge, leading to a police report. The care plan lacked elopement prevention measures, and staff failed to communicate incidents to the DON and Administrator.
The facility failed to maintain effective pest control, resulting in bed bug and cockroach infestations affecting several residents. Despite having policies in place, there was inadequate documentation of interventions and room changes. Residents reported seeing pests, and treatments were not properly documented, leading to deficiencies in pest management.
A resident with acute respiratory failure and depressive disorder was verbally abused by an LPN, who made demeaning comments. Another LPN witnessed the incident and laughed, while a CNA who also witnessed it failed to report the altercation to the Administrator, violating the facility's abuse policy.
The facility failed to post resident rights in common areas accessible to all residents. During tours, it was observed that the resident rights were not posted, and the Administrator confirmed this oversight. This deficiency had the potential to affect all 35 residents in the facility.
The facility failed to assess a resident's physical limitations and follow their abuse policy to investigate and report allegations of neglect. A resident with limited mobility and terminal prognosis reported that staff refused to assist with putting on their shoes, causing emotional distress. The incident was not properly reported or investigated, leading to a deficiency in protecting the resident from harm.
A facility failed to ensure medications were available for a resident with multiple diagnoses, leading to several supplements not being administered over a period of several months. The clinical record lacked signed physician orders to hold the medications, and the DON confirmed that the medications were not available due to incorrect documentation by a medication nurse.
The facility failed to coordinate care and services with mental health providers for a resident diagnosed with depression. Despite physician orders for behavior monitoring and mental health evaluations, the clinical record showed no follow-up services after an initial visit. The DON confirmed the lack of documentation and coordination with mental health providers.
Failure to Provide SNF ABN to Residents Remaining After Skilled Service Discharge
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents who were discharged from skilled services but remained in the facility, despite having Medicare benefit days remaining. Record reviews showed that both residents were admitted for skilled services and later discharged from those services, yet no ABN was given to inform them of their potential financial liability for services not covered by Medicare. During an interview, the administrator acknowledged being unaware of the requirement to provide the ABN form to residents who stayed in the facility after discharge from skilled services.
Failure to Timely Submit MDS Assessment Data
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for four out of twelve sampled residents. According to the facility's policy, resident assessments are to be conducted and submitted in accordance with federal and state submission timeframes. Record review showed that quarterly and annual assessments for these residents were completed but not submitted within the mandated period, with submission and acceptance dates exceeding the allowed timeframe. The Director of Nursing (DON) confirmed that the assessments for these residents were submitted outside the 14-day window required by CMS guidelines.
Failure to Administer Medication as Ordered and Document Omissions
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for one resident who was prescribed Synthroid (levothyroxine) 25 micrograms in the morning for hypothyroidism. Review of the medication administration records for March, April, and May revealed multiple dates with blanks for levothyroxine, indicating missed doses. The facility's policy required that all physician orders be followed as prescribed and that any deviations be documented in the resident's medical record during the shift. However, both the CMA and the DON confirmed that blanks on the medication administration record meant the medication was not administered, and there was no documentation explaining why the doses were missed. The pharmacy had previously identified these omissions and confirmed with the physician that the administration time should not be changed, but the issue persisted without proper documentation or explanation.
Inaccurate Coding of MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessment data for two of twelve sampled residents. For one resident, the annual assessment dated 03/23/25 had both the functional assessment and pain section marked as not assessed, despite the resident being on routine pain management. The Director of Nursing (DON) confirmed that the assessment was incomplete and not accurate, noting that the corporate nurse had completed the assessment but could have delegated the unassessed areas to a facility nurse. For another resident, the quarterly MDS assessment dated 03/18/25 did not indicate that the resident was on hospice services, even though a physician order dated 06/30/24 documented the resident's admission to hospice. The DON confirmed that the resident had been on hospice since 06/30/24 and that the MDS assessment should have reflected this status.
Failure to Obtain Physician Orders for Oxygen Therapy
Penalty
Summary
A deficiency occurred when the facility failed to ensure that physician orders for oxygen therapy were obtained for a resident with end stage chronic obstructive pulmonary disease (COPD). Record review showed that the resident was found resting in bed with oxygen administered at 4 liters per minute via nasal cannula, and their oxygen saturation was 88%. The only documented physician order for oxygen had been discontinued several months prior, with no current orders in place for oxygen therapy. The Director of Nursing confirmed that there were no active orders for oxygen, despite the resident consistently requiring oxygen due to their medical condition.
Lack of Physician Order for Indwelling Catheter
Penalty
Summary
A deficiency was identified when a resident with diagnoses of neuromuscular dysfunction of the bladder and alcoholic cirrhosis of the liver with ascites was observed with an indwelling catheter in place, but there was no corresponding physician's order for the catheter in the resident's medical record. The resident was seen sitting on the side of the bed with a catheter bag attached to a walker. Review of the physician orders dated the following day confirmed the absence of an order for the indwelling catheter. The Director of Nursing confirmed that an order should have been present for the catheter.
Undated Multidose Vial of Tuberculin PPD in Medication Storage Room
Penalty
Summary
During an observation of the medication storage room, a multidose vial of Tuberculin PPD was found to have been opened without being dated. The Assistant Director of Nursing (ADON) confirmed that the vial should have been dated upon opening. This observation was made in a facility housing 28 residents. No information was provided regarding the medical history or condition of any specific residents at the time of the deficiency.
Failure to Supervise and Implement Interventions for Resident with Exit-Seeking Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and implement appropriate interventions for a resident with known exit-seeking and wandering behaviors. The resident, who had diagnoses including dementia, impulse disorder, schizophrenia, and gait abnormalities, was repeatedly assessed as high risk for wandering, with multiple documented high scores on the facility's wandering risk scale. Despite these assessments and documented incidents of wandering and exit-seeking, the resident's care plan was not updated to address these risks until after a significant elopement event. The resident was able to leave the facility on two separate occasions. On the first occasion, dietary staff observed the resident exiting through the front door and found them in the parking lot. The care plan was not updated following this incident, and no new interventions were implemented to address the ongoing risk. On the second occasion, the resident eloped and was found approximately half a mile away from the facility on a busy four-lane road. Staff interviews revealed inconsistent awareness of the resident's elopement risk, with some staff unaware of the risk until after the elopement occurred, and others stating they had not received training on wandering until after the incident. Observations and interviews indicated that exit doors were equipped with alarms and egress releases, but there were reports of alarms malfunctioning or not being heard at the time of the elopement. Staff were unclear on how the resident exited the building, and documentation showed that the care plan lacked specific interventions for wandering and elopement until after the second elopement event. The facility's failure to update the care plan and provide adequate supervision and interventions for a resident at high risk for elopement led to the deficiency.
Failure to Timely Update Care Plan for High-Risk Wandering and Elopement
Penalty
Summary
The facility failed to develop and update a care plan with appropriate interventions for a resident identified as high risk for wandering and elopement. Despite multiple assessments and incident reports indicating the resident's ongoing high risk and actual incidents of wandering and elopement, the care plan was not revised in a timely manner to address these risks. The resident, who had diagnoses including dementia, impulse disorder, schizophrenia, and mobility abnormalities, was repeatedly observed ambulating throughout the facility and was even found outside the building on one occasion. Documentation showed that the resident's risk for wandering was consistently high, as reflected in several wandering risk scale assessments. The care plan initially did not address the resident's high risk for wandering and elopement, and only included interventions for diversionary activities. No updates or changes were made to the care plan following incidents of exit-seeking behavior and actual elopement until several months after admission. Staff interviews confirmed that there was a lack of care plan updates and intervention changes, and the DON acknowledged that the absence of a care plan coordinator contributed to the delay in updating the care plan to reflect the resident's needs.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Oklahoma State Department of Health (OSDH) within the required two-hour timeframe for three residents. Resident #13, who had intact cognition, experienced repeated incidents where Resident #24, who had significant cognitive impairment, entered their room naked and attempted to take personal items. Despite Resident #13's complaints and the staff's awareness of these incidents, the facility did not report the situation as sexual abuse until prompted by the survey agency. The administrator acknowledged the behavior as sexual abuse but only reported misappropriation initially. Resident #24, diagnosed with dementia and other mental health disorders, frequently entered other residents' rooms naked, taking their belongings. The facility's records documented multiple instances of this behavior, yet no incident reports were filed for these occurrences until much later. Staff interviews revealed that the behavior was considered normal by some, and the administrator admitted to not reporting the incidents as sexual abuse until after being prompted by the survey agency. Resident #82, with moderate cognitive impairment, alleged being physically abused by staff members. The resident called the police, and the facility was made aware of the allegation when the police arrived. However, the abuse was not reported to OSDH within the required timeframe, and the accused staff members were not suspended immediately due to staffing issues. The administrator was not informed of the incident until several hours later, and the facility's abuse policy was not followed, as the incident was reported to OSDH late, and the administrator was not notified promptly.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse involving two residents. Resident #13, who had intact cognition, reported that Resident #24, who had significant cognitive impairment, frequently entered their room naked and attempted to take their belongings. This behavior was observed by staff and reported by Resident #13, who expressed annoyance and a desire for the behavior to stop. Despite these incidents occurring multiple times daily, the facility did not investigate the situation as a potential case of abuse. Resident #24, diagnosed with dementia and other mental health disorders, was documented in progress notes as repeatedly entering other residents' rooms without clothing and taking their belongings. Staff, including a CNA and an LPN, acknowledged the behavior and reported it to the administrator. However, the administrator only reported the incidents as misappropriation and did not consider them as potential sexual abuse until prompted by the survey agency. This lack of immediate investigation into the allegations of abuse constitutes a deficiency in the facility's compliance with its abuse policy.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for two of the twelve sampled residents. According to the facility's policy, revised in July 2017, resident assessments should be conducted and submitted in accordance with federal and state submission timeframes. However, the quarterly assessments for two residents, completed on September 25, 2024, were not submitted until November 5, 2024, exceeding the required submission period. During an interview on November 7, 2024, the MDS coordinator stated that the policy allowed for a 14-day submission period from the date of completion. Upon reviewing the assessments for the two residents, the coordinator confirmed that the assessments were not submitted within the 14-day timeframe as required by CMS guidelines.
Failure to Monitor and Log Kitchen Equipment Temperatures
Penalty
Summary
The facility failed to ensure proper monitoring and logging of dish machine temperature, sanitizer concentration, and refrigeration temperatures, which are essential for safe food handling and storage. During two kitchen observations, it was noted that the facility's Dishwashing Machine Use policy, revised in March 2010, required these parameters to be monitored and recorded in an approved log. However, on November 5, 2024, there were no logs observed for refrigeration equipment temperatures. Additionally, a staff member was seen testing the dish machine temperature and sanitizer concentration, but the October 2024 dish machine temperature document on the wall showed no evidence of being used. The dietary manager admitted that the dish machine should be tested and logged before each meal shift and acknowledged that this had not been done. Furthermore, the dietary manager confirmed that refrigeration temperatures were not being logged as required.
Failure to Inform Resident of Psychotropic Medication Treatments
Penalty
Summary
The facility failed to ensure that a resident and/or their legal representative was informed in writing about the treatments and side effects of psychotropic medications. This deficiency was identified for one of the five sampled residents who were reviewed for education, alternative treatments, and consents for psychotropic medication treatments. The Director of Nursing (DON) acknowledged that they did not complete the necessary consents, education, and alternative treatments for the psychotropic medications, despite being aware that these should have been completed. The resident involved was admitted with multiple diagnoses, including dementia, schizoaffective-bipolar type, delusional disorder, depression, and obsessive-compulsive behavior. The resident's admission assessment indicated severe cognitive impairment and documented the routine use of antipsychotic, antianxiety, and antidepressant medications. The resident's electronic health record (EHR) lacked documentation of consents, education, and alternative treatments for the prescribed psychotropic medications, which included Vistaril, Seroquel, lorazepam, and Depakote.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several observations and interviews. The facility's Safe Environment policy mandates maintaining temperature levels between 71 and 81 degrees Fahrenheit. However, on the morning of November 5th, the temperature in the dining room and several resident rooms was recorded below the minimum required level, with temperatures ranging from 68.3 to 69.3 degrees Fahrenheit. Residents were observed wearing coats and using blankets to keep warm, indicating discomfort due to the low temperatures. The maintenance supervisor confirmed that the heat was not turned on and admitted to not having access to the thermostat program. Additionally, a safety hazard was identified in the form of a damaged wall leading into the dining room from the common area. The wall had missing sheetrock and a protruding sharp metal strip, posing a risk of injury to residents, especially those using wheelchairs. The maintenance supervisor acknowledged the damage, attributing it to residents hitting the wall with their wheelchairs, and admitted that repairs had not been made. Both a CNA and the DON recognized the potential for skin tears and agreed that the damaged wall did not contribute to a safe, comfortable, and homelike environment.
Failure to Prevent Sexual Abuse in LTC Facility
Penalty
Summary
The facility failed to prevent sexual abuse for a resident who was repeatedly subjected to inappropriate behavior by another resident. The affected resident, who had a cerebral aneurysm and muscle wasting with atrophy, had intact cognition and reported that another resident frequently entered their room naked, causing distress. This behavior was observed by staff, and the affected resident expressed annoyance and a desire for the incidents to stop. The resident who exhibited the inappropriate behavior was admitted with diagnoses including dementia, schizoaffective/bipolar type, and delusional disorder, and had significantly impaired cognition. This resident was documented to have entered other residents' rooms multiple times while naked, taking belongings and refusing to wear clothes. Staff noted these behaviors in progress notes, indicating that the resident was redirected back to their room multiple times, but the behavior persisted. Staff members, including a CNA and an LPN, acknowledged the frequency of these incidents and reported them to the administrator. The administrator confirmed that the behavior was considered sexual abuse but initially only reported misappropriation. The facility's policy on abuse required documentation and intervention, but the repeated incidents suggest a failure to effectively implement measures to protect residents from such behaviors.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy effectively, as evidenced by two significant incidents involving residents. In the first case, a resident with intact cognition was repeatedly subjected to another resident entering their room naked and attempting to take personal items. This behavior was reported to occur multiple times daily since the second resident's admission, yet the facility did not take immediate action to prevent further occurrences or report the incidents as abuse until prompted by the state agency. The administrator acknowledged the behavior as potential sexual abuse but only reported it as misappropriation initially. In the second incident, a resident with moderately impaired cognition alleged physical abuse by two staff members. The resident called the police to report being thrown against a wall, and the police informed the facility staff of the allegation. However, the facility did not follow its abuse policy, as the incident was not reported to the administrator within the required timeframe, and the accused staff members were not suspended immediately due to staffing issues. The administrator was only informed of the allegation hours later when visiting the resident at the hospital. These incidents highlight the facility's failure to adhere to its abuse policy, which mandates immediate reporting and investigation of abuse allegations and the implementation of measures to prevent further abuse. The lack of timely reporting and action in both cases indicates a significant deficiency in the facility's handling of abuse allegations, potentially compromising resident safety and well-being.
Failure to Include Hospice Services in Care Plan
Penalty
Summary
The facility failed to ensure that hospice services were included in the care plan for a resident with diagnoses of senile degeneration of the brain and dementia. The facility's policy stated that care plans should identify priority problems and needs, and be complete and current. An Order Summary Report indicated that the resident had a physician order for hospice services. However, there was no documentation that hospice services were included in the resident's care plan. During an interview, the MDS Coordinator confirmed that hospice services should be added to the care plan immediately and acknowledged that hospice services had not been added to the resident's comprehensive care plan.
Failure to Reorder Medication for Resident
Penalty
Summary
The facility failed to ensure that medications were supplied as ordered for a resident diagnosed with congestive heart failure, bipolar disorder, depression, and hypertension. The resident had a physician's order for clonidine HCL, a blood pressure medication, to be administered three times a day. During a medication pass observation, it was noted that the medication was not available in the medication cart or room. The Certified Med Aide (CMA) responsible for the medication pass confirmed that the clonidine had not been reordered from the pharmacy or hospice, as required by the facility's policy. The facility's policy, revised in July 2023, mandates that medications be reordered at least three days before the last dosage is administered. However, there was no documentation to show that the medication had been reordered. The Director of Nursing (DON) stated that CMAs were responsible for reordering medications and that they would investigate if medications did not arrive on time. The DON was not informed about the shortage of clonidine until after the issue was identified during the survey. This lack of communication and failure to adhere to the medication reordering policy led to the deficiency.
Failure to Implement Physician Orders for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a physician order was completed for a resident reviewed for unnecessary medications. The resident had diagnoses including senile degeneration of the brain, dementia with other behavioral disturbances, and bipolar type. A pharmacy report documented a signed physician order to change the order for Risperdal to 0.5 mg in the morning and 1 mg at bedtime, and to discontinue Zyprexa. However, the order was not implemented as the resident continued to receive Risperdal 0.5 mg twice a day and Zyprexa 2.5 mg at bedtime, as documented in the October and November 2024 MARs. The Director of Nursing (DON) acknowledged that the order was not changed as per the physician's instructions. The facility's policy required that the nurse who received the order or the DON, if they noted the order, input the new order into the computer. Despite this policy, the order to adjust the medication was not followed, leading to the resident continuing on the previous medication regimen. This oversight was identified during a review of the pharmacy document and confirmed by the DON.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as an elopement risk, leading to multiple elopement incidents. The resident, who was admitted with a history of dementia, Alzheimer's disease, and other mental health conditions, was recognized by family as an elopement risk upon admission. Despite this, a care plan addressing the risk was not initiated until several months later, and even then, it was not updated following the resident's first elopement incident. On two separate occasions, the resident managed to leave the facility unsupervised. The first incident occurred when the resident was found several blocks away, and the care plan was not updated to include new interventions. The second incident involved the resident crossing a railroad track and a four-lane freeway, highlighting the inadequacy of the existing supervision measures. The facility's monitoring tools also showed gaps in documentation, indicating that the resident was not consistently monitored as per the care plan. The facility's policy required the involvement of the interdisciplinary team (IDT) in decision-making regarding interventions to prevent elopement, but this was not followed. The Director of Nursing (DON) admitted to making decisions without consulting the IDT and was unaware of the resident's previous elopement history. The lack of clear and updated care plans, combined with insufficient staff training and supervision, contributed to the repeated elopement incidents.
Failure to Update Care Plan for High-Risk Elopement Resident
Penalty
Summary
The facility failed to update a care plan for a resident who was at high risk for elopement, despite multiple documented incidents of the resident going missing. The resident, who had diagnoses including dementia, Alzheimer's disease, and other mental health disorders, was initially identified as an elopement risk with a care plan initiated to address this risk. However, after the resident was found missing on two separate occasions, the care plan was not revised to include additional interventions to ensure the resident's safety. The Director of Nursing (DON) was unaware of the resident's previous elopements and did not understand the interventions outlined in the care plan. Despite assessments indicating a high risk for wandering and elopement, the care plan remained unchanged from its original version, lacking clarity and necessary updates to address the resident's ongoing risk. This oversight resulted in a failure to adequately monitor and protect the resident, as evidenced by the repeated elopement incidents.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent the elopement of a resident diagnosed with Alzheimer's, dementia, and delusional disorder. The resident, identified as being at low risk for wandering, was able to leave the facility on multiple occasions without proper supervision. On one occasion, the resident signed out and left the facility without informing staff, leading to a police report being filed when the resident was found at a family member's house. Despite being placed on 1:1 supervision, documentation was incomplete, and the resident continued to attempt to leave the facility. The facility's elopement policy required staff to investigate and report all cases of missing residents, but there was a lack of documentation and communication regarding the resident's elopements. The Director of Nursing (DON) and other staff members were unaware of the resident's whereabouts on several occasions, and the care plan did not include measures for elopement prevention. The Administrator and DON were not fully informed of the incidents, and the state incident report was not filed promptly. Interviews with staff and family members revealed that the resident had a history of attempting to leave the facility, and the family was concerned about the resident's safety. The facility's failure to document and communicate the resident's elopements, as well as the lack of a comprehensive care plan, contributed to the deficiency in providing a safe environment for the resident.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of bed bugs and cockroaches affecting multiple residents. The pest control policy was undated, and the bed bug prevention policy was last revised in 2011. Despite having a pest control program in place, there were documented instances of bed bugs and roaches in the facility. A pest control invoice noted bed bug evidence in a specific room, and a maintenance work order documented roaches in another resident's room. Residents reported seeing cockroaches and experiencing bed bug infestations, with one resident noting itching and bed bugs in their room even after treatment. The facility's response to the pest issues was inadequate, as there was no documentation in the clinical health records regarding room changes, resident responses, or interventions implemented. Residents were moved due to bed bug infestations, but the facility failed to document these actions properly. The bed bug service agreement did not specify which areas were treated, and the administrator confirmed that two rooms had been treated for pests. The lack of documentation and effective pest control measures contributed to the deficiency, impacting the residents' living conditions.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to ensure staff followed their policy to report an allegation of abuse to the Administrator. The incident involved a resident with acute respiratory failure and depressive disorder, who was verbally abused by an LPN. The altercation occurred near the nurses' station, where the resident called the LPN a derogatory term, and the LPN responded with demeaning comments comparing the resident to a pig. Another LPN witnessed the incident and laughed, while a CNA who also witnessed it did not report the altercation to the Administrator, as required by the facility's abuse policy.
Failure to Post Resident Rights
Penalty
Summary
The facility failed to ensure that resident rights were posted in common areas accessible to all residents. This deficiency was identified during tours of the common areas on two separate occasions. On both occasions, the resident rights were not located. When questioned, the Administrator confirmed that the resident rights were not posted in any of the common areas. This failure had the potential to affect all 35 residents in the facility, as identified by an LPN who confirmed the census count.
Failure to Assess Physical Limitations and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to assess a resident's physical limitations and follow their abuse policy to fully investigate and report allegations of neglect. Resident #5, who had diagnoses including bipolar disorder, chronic pain, congestive heart failure, and morbid obesity, reported that staff refused to assist with putting on their shoes. Despite the resident's limited physical mobility and terminal prognosis, staff allegedly told the resident to put on their own shoes, causing the resident significant distress. The resident expressed that this neglectful behavior occurred frequently and caused them emotional pain, leading to crying and sobbing during the interview. The facility's policy on abuse, neglect, and exploitation was not followed, as the incident was not reported or investigated properly by the staff involved. On the day of the incident, the resident reported the issue to the Assistant Director of Nursing (ADON), but the grievance was not handled according to the facility's abuse policy. The Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) involved did not report the event immediately, and the Administrator admitted to not considering a neglect investigation. The facility's failure to assess the resident's physical limitations and properly investigate the allegations of neglect and psychological abuse led to a deficiency in protecting the resident from harm and ensuring their dignity and autonomy.
Failure to Ensure Medication Availability
Penalty
Summary
The facility failed to have a system in place to ensure medications were available for one of the three sampled residents reviewed for medication availability. The resident had diagnoses including ankylosing spondylitis, depressive episodes, and anxiety. Physician orders documented that the resident was to be administered several supplements, including Elderberry Immune Complex, Turmeric, and Vitamin E. However, the Medication Administration Record (MAR) showed that these medications were held and not administered on multiple occasions from December 2023 to March 2024. The clinical record did not contain signed physician orders to hold the medication, nor was there an entry indicating that the physician had been notified with the rationale for not administering the medications. On March 13, 2024, an LPN reviewed the MAR documentation and stated they were unaware of any medications being on hold but noted that the resident liked to order their own medications. The Director of Nursing (DON) later confirmed that a medication nurse was aware the resident did not have the medications available and had documented the wrong information in the computer, creating a hold order without a physician's authorization. The medications had not been available to administer to the resident, leading to the deficiency noted in the report.
Failure to Coordinate Mental Health Services
Penalty
Summary
The facility failed to coordinate care and services with mental health providers for a resident diagnosed with depression. Despite having physician orders for behavior monitoring and mental health evaluations, the clinical record showed that the resident had not received mental health services after a visit on 07/23/23. The resident's care plan included instructions for mental health evaluations and treatments, but there was no documentation of follow-up services. The resident exhibited verbal behavioral symptoms and rejected care, which interfered significantly with their care, yet no further mental health services were documented after the initial visit. When questioned, the Director of Nursing (DON) confirmed that the clinical record only contained documentation of the resident being seen on 07/23/23. The DON admitted that the facility did not always know which residents were being visited by mental health providers and usually did not receive progress notes, only orders if changes were made. This lack of coordination and documentation led to the failure in providing necessary behavioral health care and services to the resident.
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 31 citations issued within 25 miles in the last 12 months — including the 2 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) |
|---|---|---|---|---|
| River Valley Skilled Nursing And Therapy | 0.9 mi | ★★★★★ | 3 | 0 |
| Corn Heritage Village And Rehab | 14 mi | ★★★★★ | 4 | 2 |
| Cordell Nursing And Rehabilitation | 14.1 mi | ★★★★★ | 18 | 0 |
| Corn Heritage Village And Rehab Of Weatherford | 15.8 mi | ★★★★★ | 0 | 0 |
| Maple Lawn Nursing And Rehabilitation | 22.5 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Clinton Therapy & Living 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 June 2026) and official state health department websites.