The Waters Of Clinton, LLC

Based on facility policy review, observation, and interview the facility failed to maintain a clean and sanitary kitchen which had the potential to affect 90 of 90 residents of the facility.The findings include:Review of the facility's policy titled, Labeling and Dating, dated 7/30/2023, revealed .leftovers and opened foods shall be clearly labeled with date food item is to be discarded .Review of the facility's undated policy titled, Equipment Cleaning and Sanitizing revealed .Equipment is washed, rinsed, and sanitized after each use to ensure safety of food served to residents .Employees who use equipment will be responsible for washing and sanitizing removeable parts after each use. Steps include .Disassemble removable parts from equipment .wash, rinse, and sanitize all food contact surfaces and the equipment that are sanitary .During an observation and interview on 9/21/2025 at 10:30 AM, 6 sandwiches in plastic bags identified by staff as peanut butter and jelly were in the kitchen refrigerator. Continued observation revealed 5 of the 6 sandwiches were unlabeled and undated. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interviews, the facility failed to obtain consent for administration of psychotropic medications for 2 of 5 residents (Resident #10 and Resident #24) reviewed for unnecessary medications. The findings include:Review of the facility's undated policy titled, Psychotropic Drugs Usage, revealed .Any resident receiving psychotropic medication will have a signed informed consent for the use of the medication .Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Severe Dementia with Psychotic Disturbance and Delusional Disorder. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident received an antidepressant medication.Review of current Physician Orders for Resident #10 revealed Sertraline…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review and interview, the facility failed to ensure the electronic medical records of the facility were protected by using safeguards to ensure the electronic medical records were not available for direct public to view within the facility. The findings include:Review of the facility's undated policy titled, What is HIPAA, revealed .It is the health insurance portability and accountability act of 1996 (HIPAA) .A major goal of the privacy rule is to assure that individual's health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well-being .Any and all health information on a resident or employee that identifies an individual. This can be in any form, such as paper records, electronic records, and even spoken communication .It shall be the policy of the facility to protect and safeguard the PHI (personal health information) created, acquired and maintained in accordance with the Privacy Regulation pursuant to the Health Insurance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, and interviews, the facility failed to ensure MDS assessments were accurate for 1 resident (Resident #65) of 22 residents reviewed for MDS assessments. The findings include: Review of the MDS (Minimum Data Set) 3.0 RAI Manual Verson 19.1, dated 10/2024, revealed .SECTION H: BLADDER AND BOWEL .The intent of the items in this section is to gather information on the use of bowel and bladder appliances .provided with individualized treatment .Appliances .INDWELLING CATHETER A catheter that is maintained within the bladder for the purpose of continuous drainage of urine .Health-related Quality of Life .It is important to know what appliances are in use and the history .Steps for Assessment .Check next to each appliance that was used at any time in the past 7 days. Select none of the above if none of the appliances .were used in the past 7 days . Review of the medical record revealed Resident #65 admitted to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to obtain a Physician's Order for isolation precautions for 1 resident (Resident #12) of 16 residents reviewed for isolation orders. The findings include: Review of the facility's policy titled, Infection Control/Isolation Guidelines, undated, revealed .to prevent unprotected exposure of residents, visitors, and staff to potentially infectious microorganisms .to decrease the spread Contact precautions used for multidrug-resistant organisms [MDRO's] [microorganisms, primarily bacteria, that have developed resistance to 3 or more antimicrobial drugs making them difficult to treat with standard antibiotics] .and order must be obtained from the physician .Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Anxiety Disorder, and Major Depressive Disorder. Review of a Laboratory Result reported to the facility on 9/16/2025, revealed Resident #12 had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, observation, and interview, the facility failed to ensure medications were securely stored in 1 medication cart (North medication cart) of 4 medication carts reviewed.The findings include: Review of the facility policy titled, Medication Storage in the Facility, dated 3/2023, revealed .Medications are stored safely, securely, and properly .accessible only to licensed nursing personnel .Medication rooms, carts, and medication supplies are locked and attended by person with authorized access . During an observation on 9/21/2025 at 1:14 PM, the North medication cart was located in the North hallway against the wall, and the drawers were facing the hallway. The medication cart was unlocked and there were no employees present. During an interview on 9/21/2025 at 1:15 PM, LPN D confirmed she had been in a resident room with the door closed and the North medication cart in the hallway was unlocked, and out of LPN D's view. LPN D also confirmed medication carts are to be locked when unattended by the licensed nurse.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was donned for 1 resident (Resident #9) of 16 residents observed on Enhanced Barrier Precautions (EBP), and the facility failed to perform hand hygiene during medication administration for 1 resident (Resident #10) of 4 residents observed during medication administration.The findings include: Review of the facility's policy titled, Guidelines for Enhanced Barrier Precautions, undated, revealed .Enhanced Barrier Precautions (EBP) is defined as the use of PPE (gowns and gloves) during high-contact resident care activities that generate opportunities for transfer of multidrug-resistant organisms [MDRO's] [microorganisms, primarily bacteria, that have developed resistance to 3 or more antimicrobial drugs making them difficult to treat with standard antibiotics] .onto the hands and/or clothing of the rendering caregiver .for residents at high-risk for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the Centers for Disease Control (CDC) guidance, review of facility policy, interview, and observation, the facility failed to ensure 6 COVID-19 unvaccinated staff of 6 unvaccinated staff observed, donned appropriate Personal Protective Equipment (PPE) to ensure precautions were taken to properly prevent COVID-19 transmission in the facility. The findings include: Review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 2/2/2022, showed .Eye protection (i.e. [for example], goggles or a face shield that covers the front and sides of the face) . Review of the facility policy titled, Mandatory COVID-19 Vaccination Policy, revised 11/5/2021, showed .Unvaccinated staff will need to wear a face shield, goggles and an N95 mask at all times . Review of the facility policy titled, COVID-19 Residents and Staff Testing, revised 3/31/2022, showed .Unvaccinated staff with exemptions .If a facility staff member has an exemption .Staff are required to wear an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility documentation review, and interview the facility failed to maintain ongoing written communication between the facility and the dialysis center for 1 resident (Resident #30) of 1 resident reviewed for dialysis. The findings include: Review of the facility policy titled Community Hemodialysis, undated, showed .A dialysis communication sheet will return with the resident after the dialysis session to communicate to the facility information regarding the dialysis session . Resident #30 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Type 2 Diabetes Mellitus, Dependence on Renal Dialysis, Hypertension, and Anxiety Disorder. Review of the Comprehensive Care Plan initiated on 2/11/2022, showed Resident #30 was care planned for .End Stage Renal Disease .hemodialysis . Interventions included .Written communication form with review of weight and any changes in condition between dialysis provider and living center . Review of a physician's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, The facility failed to develop and implement a behavioral health care plan for 1 resident (Resident #23) diagnosed with Dementia of 5 residents reviewed for Dementia and behavioral care plans. The findings include: Review of the facility's undated policy titled, BEHAVIOR MANAGEMENT PSYCHOTROPIC MEDICATION PROTOCOL, showed .Residents who receive antipsychotic antidepressant sedative/hypnotic or antianxiety medications .will be reviewed routinely for effectiveness and monitored for side effects of those medications .Newly admitted residents .update the Care Plan to include the problem behavior, goals and approaches .establish behavior program and complete a Behavior/Intervention Monthly flow record for those residents identified as having behaviors. Appropriate updating and/or revisions to the Care Plan will be done .by the Interdisciplinary Care team [IDT] .The committee [IDT] will .routinely review the resident as long as the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to provide behavioral monitoring and failed to monitor for side effects of psychotropic and anti-depressant medications for 2 residents (Resident #23 and Resident #62) of 5 residents reviewed for behavior monitoring and psychotropic medication use. The findings include: Review of the facility's undated policy titled, BEHAVIOR MANAGEMENT PSYCHOTROPIC MEDICATION PROTOCOL, showed .Residents who receive antipsychotic antidepressant sedative/hypnotic or antianxiety medications .will be reviewed routinely for effectiveness and monitored for side effects of those medications .Newly admitted residents .update the Care Plan to include the problem behavior, goals and approaches .establish behavior program and complete a Behavior/Intervention Monthly flow record for those residents identified as having behaviors. Appropriate updating and/or revisions to the Care Plan will be done .by the Interdisciplinary Care team [IDT]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Centers for Disease Control (CDC) and Prevention guidance, review of facility policy, observations, and interviews, the facility failed to ensure infection control practices were followed for 3 residents (Resident #85, Resident #340, and Resident #342) of 6 residents reviewed for transmission-based precautions and failed to ensure appropriate precautions were taken to prevent COVID-19 transmission in the facility. The findings include: Review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 2/2/2022, showed .Eye protection (i.e. [for example], goggles or a face shield that covers the front and sides of the face) . Review of the facility's undated policy titled, COVID-19 PPE [Personal Protective Equipment] Zones Guidelines, showed .PPE for all zones .YELLOW ZONE- SUSPECTED OR PRESUMED COVID-19 UNIT .Mask (N95 if adequate supply, may use surgical mask if not), gown,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to develop a comprehensive care plan for 1 Resident (#61) of 3 residents reviewed for dialysis. The findings include: Review of medical record review showed Resident #61 was admitted on [DATE], readmitted on [DATE], with diagnoses including Peripheral Vascular Disease, End Stage Renal Disease, Diabetes and Hypertension. Review of the care plan, updated 12/23/2019, showed the resident had renal failure and the potential for complications related to hemodialysis. The care plan did not address Resident #61's type of hemodialysis access or the location of the access site. Interview Assistant Minimum Data Set (MDS) Coordinator on 2/24/2020 at 2:00 PM, stated Resident #61's care plan was to address the type of hemodialysis access and where the access site was located. The resident's care plan does not address the type of hemodialysis access or the location of the access site.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, record review, observation, and interview, the facility failed to change oxygen tubing and replace humidifier bottles for 2 residents (#60 and #72) of 8 residents reviewed for oxygen use. The findings included: Review of the facility policy titled, O2, [Oxygen] undated, showed .Tubing, humidifier bottles and filters will be changed, cleaned and maintained by the facility . Review of the medical record, showed Resident #60 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Hypertension, Dementia, Bipolar Disorder, Schizoaffective Disorder, and Atherosclerotic Heart Disease. Review of the physician's order dated 4/11/2019, revealed an order for oxygen at 3 liters per minute (LPM) via nasal cannula (device to administer oxygen through the nares of the nose). Observation of the resident's room on 2/23/2020 at 10:50 AM, showed Resident #60 was wearing oxygen at 3 LPM via nasal cannula and the tubing and water bottle for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.