Clinton Nursing & Rehabilitation Center

9211 STUART LANE
CLINTON, MD 20735
(301) 868-3600

• Located in Prince George's County, Maryland
• For-profit corporation own by Comunicare
• Certified beds: 267 (very large nursing home)
• Last Medicare rating: 1 star

According to Medicare, Clinton is a for-profit corporation owned by White Oak Healthcare LLC and WO Nursing Parent LLC, which took possession in 2007 and have run the facility jointly since then. These companies are owned by CommuniCare which is a growing at the speed of light nursing home chain based in Ohio that our nursing home lawyers are seeing more and more.

This nursing home was sued in 2012 in a wrongful death claim filed in Prince George's County. The lawsuit alleged that the nursing home failed to properly care for the patient by failing to check his skin (presumably a bed sore case).

Something very odd is going on at Clinton Nursing & Rehabilitation Center. By some measures, this facility seems to be a contender for rock-bottom last place among nursing homes in general. By other measures, Clinton's recent performance has been markedly better than that of most nursing homes. How to account for this vast discrepancy? Read on, for we do have a theory. Remember, though: it's only a theory.

Before we dig into the (abysmal) record of Clinton Nursing & Rehabilitation, let's look at the competition in Clinton:

• FutureCare Pineview: This FutureCare facility is a half of a mile way. While it is impossible to call Pineview an objectively high-quality nursing home, it certainly has a much better rating that Clinton.
• Bradford Oaks Center: A very poorly rated Genesis owned nursing home that is less than two miles away (down Branch Avenue).
• Medstar Southern Maryland Hospital Center: Even a nursing home attorney cannot criticize this facility. It is on the same street as Bradford Oaks. But it is too good to be true. It has just 24 beds and is only for short-term stays.

Medicare gave Clinton the "much below average" 1-star rating in its last standard inspection (May, 2015). Remember the average nursing home in this country is not very good. You cannot get any lower than a one star rating. It is not hard to draw some pretty strong conclusions when you merge these two facts.

The health-inspection part of the Medicare survey counted 24 deficiencies at this facility - a whopping big number compared with the Maryland state average (11) and the U.S. average (7.1). The inspectors found deficiencies in seven out of eight measured categories -- including 8 deficiencies for quality of care; 6 for environmental issues; 5 for resident assessment; and 1 for mistreatment. This facility also scored below average on nurse staffing and fire safety.

Making all these bad numbers even more serious is the fact that they could affect so many people. Clinton is huge: its resident population of 258 (per the last official count) dwarfs the average populations for Maryland (107.5) and the U.S. overall (86.2). The good news is that Clinton scored above average for quality measures - stats that, arguably at least, give a numerical gauge of the residents are doing.

But first, there is more bad news. In addition to performing standard inspections of nursing homes, Medicare will conduct a complaint inspection when so warranted. The best nursing homes probably will have no complaint inspections, although even a good facility might have had one (or even two) in recent years. Since September, 2015, Clinton has had three - in which authorities investigated 14 different complaints affecting many residents, and found some issues that were serious as death.

As part of its routine, Medicare reports the level of harm that each complaint issue posed for residents. In many cases Medicare will conclude that there was "minimal harm or potential for actual harm." At Clinton, the complaint inspectors found the harm level, in one case, to be "immediate jeopardy" for some residents.

Immediate jeopardy. It's as serious as it sounds. In its three complaint inspections since 2015, Clinton also was found to have exposed residents to "actual harm" in three separate cases. Due to the sheer number of complaints, we will attempt here only to give a summary of them, starting with the most egregious items.

In that immediate jeopardy case, Medicare found that Clinton "failed to ensure… that the nutritional needs of residents were met." Five residents were so affected. In the first case, Clinton staffers failed to provide adequate nutrition to one resident "for 17 months." The report noted that "the resident's weight was maintained in a stable but severely underweight status." In effect, this resident spent 17 months slowly starving to death. And this resident had pressure ulcers (i.e., bedsores) - for which the body requires nutrition to heal; so the undernourishment routine could only exacerbate the situation. (For more information about pressure ulcers, go to https://www.millerandzois.com/maryland-pressure-sore-lawyer.html.) "After 17 months of nutritional neglect," Medicare stated, "the nursing home Medical Director signed the [resident's] death certificate," stating that the cause of death was "Failure to Thrive." (It seems that Clinton felt the death was the resident's fault.) This Medicare complaint report went on to cite the cases of four other Clinton residents, all suffering drastic weight loss (for instance, 17 percent of a person's body weight in a single month).

Inspectors found "immediate jeopardy" at Clinton during their complaint inspection of February 2, 2016. Another complaint they addressed during the same inspection was that by failing to treat or prevent pressure ulcers, this facility did "actual harm" to at least four residents.

For one resident the issue was ongoing negligence by the facility: no adequate assessment of the resident's needs and an inadequate response as the resident developed new pressure ulcers. The resident died. In a second case, Clinton did not determine the level of nutrition a resident needed to recover from pressure ulcers; in fact, the facility put the resident on a feeding regimen significantly lower in protein than necessary for bed sores to heal. Third case: failure to assess the resident's needs adequately; failure to provide the resident with the recommended amount of nutrition to promote healing; and even outright failure to follow a specialist's orders for treatment. Fourth case: "There is no documented evidence that the resident was ever evaluated by the dietitian related to the resident's pressure ulcers."

For most of the long list of complaints in the February 2 inspection, Medicare would determine that there was "minimal harm or potential for actual harm." However, this was hardly an endorsement. The complaints in this inspection included Clinton's failure to evaluate a resident and provide medical documentation; failure to monitor a resident's condition properly; failure to develop care plans, or discharge plans, with appropriate goals and interventions; and multiple instances of poor documentation, adversely affecting a resident's care and management…. and the list goes on.

In its prior complaint inspection, September 8, 2015, Medicare cited Clinton for doing "actual harm" to a resident through negligence, but maybe this time it wasn't really the facility's fault. (While a staffer was out of the room, seeking help, a resident tried to climb out of bed and fell to the floor.) But this complaint inspection also cited cases that seem more serious: staffers failing to administer or document treatment for skin ulcerations, or failing to take action when a resident showed signs of infection. However, Medicare decided that these cases posed "minimal harm or potential for actual harm," as did the fact (discovered, apparently, during this complaint inspection) that the facility's second floor smelled like urine.

Clinton had yet another complaint inspection on April 5, 2016, in which Medicare again decided that the complaint issues posed minimal harm or potential for actual harm. But one complaint, based on an "environmental tour" of the facility, produced a picture of a decrepit facility in which residents lived in poorly maintained quarters. Among the inspectors' observations of residential rooms: "soap dispenser empty... stains on the wall… tray table soiled... caulk at the hand sink damaged… wall damaged… door finish damaged… the toilet seat bracket rusty with peeling paint and not cleanable…. wall paint peeling… wall unclean with a dried spatter observed… door severely damaged…." And, affecting not just individual residents but all of them: "Floors throughout resident areas were soiled, with a dark buildup of material, particularly under furnishings and heating units and at the wall floor junctures."

By all the accounts so far, Clinton hardly would sound like a good facility in any regard. But it is - or at least it was, according to the latest Medicare stats. The last Medicare standard survey rated this facility 4 stars - above average - for quality measures. For short-stay residents, Clinton scored above the Maryland and U.S. averages in seven of nine measured categories. For long-stay residents, this facility outscored the state and U.S. averages in 10 of the 15 measured categories.

Clinton short-stay residents were less likely than the Maryland and U.S. averages to require rehospitalization or an ER visit after discharge; and less likely to report moderate to severe pain. They were slightly more likely than average to experience improvement in functionality; and definitely more likely to receive flu and pneumonia vaccinations. Clinton's best stat for short-term residents was in pressure ulcers (that is, bed sores): this facility had an incidence rate of 0.1 percent, which is excellent, by far beating the state and national averages of 1.3 percent.

There was, however, one decidedly negative stat for Clinton with respect to short-stay residents: Clinton's successful discharge rate was a dismal 25.4 percent - less than half the averages for Maryland (59.1 percent) and the U.S. (55 percent).

For long-term residents, Clinton was a bit below average in preventing pressure ulcers and serious weight loss; and a little under average in helping residents maintain their mobility and their ability to carry out daily activities without help. We used the bedsore barometer

Clinton was about average for incontinence rates, but better than average in using less ongoing catheterization. Clinton long-termers were found to be less likely to suffer falls with injury and less likely to need antipsychotic meds; more likely than average to receive flu and pneumonia shots.

But in five quality measures for long-stay residents, Clinton did not merely do well: its scores were outstanding. Its rate of urinary tract infections was 0.6 percent - less than one-seventh the state and national averages of 4.5 percent and 4.8 percent respectively. (For more information about urinary tract infection cases, go to

Clinton's long-termers were far less likely to report serious pain (only 2.3 percent, versus 6.4 percent statewide, 8.2 percent nationally. Clinton long-stayers were only about a third as likely as average to need antianxiety meds, and they were only about one-eighth as likely to have depression symptoms. On using physical restraints, the Maryland state average is 0.6 percent, the national average 0.8 percent; the Clinton average was zero.

It would make sense for quality measures to relate to staffing since it is the staffers who administer the care that the quality measures track. Yet while getting those four stars for quality measures, Clinton got a below-average 2-star rating on staffing.

Clinton beat the state and national averages in the category of LPNs and LVNs (licensed practical nurses, licensed vocational nurses), giving residents 63 minutes a day with these nurses (versus 52 minutes on average for Maryland, 51 minutes nationally).

But Clinton was below average in the other staffing categories, including residents' time with certified nursing assistants and physical therapists. Registered nurse time per resident here was only 30 minutes a day, versus 59 minutes on average for Maryland, 51 minutes for the U.S. overall. That's awful. For RN staffing in particular, this facility received a below-average rating of 2 stars. Total nurse time per resident at Clinton was one hour, 33 minutes, below the state average of one hour, 51 minutes, and the U.S. average of one hour, 42 minutes. Why go light on you most qualified nurses? One thing is for sure: they cost more.

Clinton is an exceptionally large facility, with two to three times as many residents as the Maryland and U.S. averages. The most recent Medicare statistics present a picture of a facility that does very well for most of its residents (4 stars on quality measures) but that it does extremely poorly by some unfortunate percentage of them (thus the complaint reports). This discrepancy may be attributable to Clinton's below-average rating on nurse staffing; combined with its dismal record of health inspection deficiencies and a complaint report that found numerous signs of physical neglect to the facility property (again pointing to staffing levels, but non-nurse staffing). So these stats suggest that Clinton is understaffed. This place may have some great nurses, as well as good staffers, who are simply stretched too thin. This is only a theory. We are not walking through this nursing home to inspect it and we have never sued this particular nursing home. We are just relying on the data. But there must be some reason that Clinton could get four stars on quality measures and yet have so many black marks on its record.

Some anecdotal accounts seem consistent with the Medicare stats, and they support the understaffing theory. Five online reviews of Clinton, all offered by individuals, each either "a friend or relative of a resident," or an actual resident pain a disconcerting picture.

The oldest of these reviews, from August 2012, gave Clinton the backhanded compliment that this facility "was not necessarily a bad one," adding that "the staff did seem friendly." On the other hand, "The atmosphere of the place just seemed rather bland and empty." The next review, in chronological order, was a February 2014 review by someone whose brother had gone to Clinton for rehabilitation. This reviewer described Clinton as adequate but lacking in basic amenities (such as phone and TV), and said that the staffers did not give the reviewer's brother any pain meds or muscle relaxants, which apparently he needed.

All three of the other reviews came in 2016 - and all three gave Clinton two thumbs down. Although these are all subjective opinions, they convey the impression that since 2012, Clinton has gotten worse.

A reviewer, whose son was at Clinton, wrote in February that "the place was filthy, smelly and seemed to lack in organization. I was quite frankly appalled with the whole experience." The reviewer expressed fear for the son's exposure to "infection in this environment." The next reviewer, in April, corroborated the previous one: "This place is the worst…. It stinks all the time." This reviewer noted that the family member residing here had been at Clinton a year earlier, and then had returned to find that "this place has drastically declined."

"One star - terrible!" Thus began the most recent review, in May 2016, from someone who went to Clinton to receive rehabilitation. The Clinton therapist ignored this resident's medical history, with the result that "my left hip had to overwork itself and needed to be replaced along with the right hip."

And this reviewer was just warming up. "The nursing, social-service, activities, and housekeeping departments… leave a great deal to be desired -- REALLY! Especially, labor (not enough housekeeping, nurses, nursing aides, social worker designees, administrators, etc.); linen (towels, wash clothes, pillowcases, etc.); scarcity seems to be an important component of their profit margin."

We would not direct you to reviews like this if the nursing home was doing well. It is, after all, only five reviews. But it fits so neatly with the objective reviews of this nursing home, it is hard not to give them credence. It would seem to be a tiebreaker between the awful rating and the rather good quality data.

• Communicare does not have a lot to say about this facility
• Getting a maximum settlement or verdict in senior living abuse and neglect cases: what is the monetary value of your nursing home claim?
• What does a nursing home wrongful death legal complaint look like?
• Call our senior neglect lawyers today at (800) 553-8082 or get a free online case review if you believe you may have a potential nursing home lawsuit in Maryland.

If someone you love is a victim of nursing home abuse or neglect, don't be a victim twice. You should take action immediately to protect your rights. Our experienced nursing home lawyers have a history of results in nursing home and medical malpractice cases in Prince George's County. We can provide counsel and direction for the best path to justice. To find out what we can do to help you, call us today for a free consultation at (800) 553-8082 or get a free online case review.

1 Vital Statistics

Number of Beds: 267 certified beds

Beds in the nursing home that have been approved by the federal government to participate in Medicare or Medicaid.

Accepts: Medicare and Medicaid

Shows if the nursing home participates in the Medicare, Medicaid, or both.

2 Key Ratings

Star Rating Summary
Overall Rating Medicare assigns the overall star rating based on a nursing homes's performance on 3 separate measures: Health inspections, staffing, and quality measures. Each of these domains have their own star ratings, with more stars meaning better quality of care		Average
Health Inspection Medicare assigns the star rating based on a nursing home’s weighted score from recent health inspections. More stars means fewer health risks		Below Average
Staffing Medicare assigns the star rating based on the nursing home’s staffing hours for Registered Nurses (RNs), Licensed Practice Nurses (LPNs), Licensed Vocational Nurses (LVNs), and Nurse aides. More stars means a better level of staffing per nursing home resident		Average
RN Staffing		Average
Quality Measures Medicare assigns the star rating based on data from a select set of clinical data measures. More stars means better quality of care		Much Above Average

3 Key Short Stay Statistics

Description	Clinton Healthcare Center	Maryland Average
Percent of short-stay residents who self-report moderate to severe pain Lower percentages are better.	0.6%	10.4%
Percentage of SNF residents with pressure ulcers that are new or worsened Lower percentages are better.	0.3%	Not Available
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine Higher percentages are better.	95.1%	85.3%
Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine Higher percentages are better.	95.7%	84.0%
Percentage of short-stay residents who got antipsychotic medication for the first time Lower percentages are better.	1.8%	1.7%

4 Key Long Stay Statistics

Description	Clinton Healthcare Center	Maryland Average
Percent of long-stay residents experiencing one or more falls with major injury Lower percentages are better.	1.3%	2.7%
Percent of long-stay residents with a urinary tract infection Lower percentages are better.	0.5%	2.5%
Percent of long-stay residents who self-report moderate to severe pain Lower percentages are better.	0.4%	5.4%
Percent of long-stay high-risk residents with pressure ulcers Lower percentages are better.	8.3%	8.8%
Percent of long-stay low-risk residents who lose control of their bowels or bladder Lower percentages are better.	70.4%	62.3%
Percent of long-stay residents who have or had a catheter inserted and left in their bladder Lower percentages are better.	1.8%	1.7%
Percent of long-stay residents who were physically restrained Lower percentages are better.	0.0%	0.2%
Percentage of long-stay residents whose ability to move independently worsened Lower percentages are better.	27.1%	22.5%
Percent of long-stay residents whose need for help with daily activities has increased Lower percentages are better.	21.1%	18.0%
Percent of long-stay residents who lose too much weight Lower percentages are better.	5.7%	5.8%
Percent of long-stay residents who have depressive symptoms Lower percentages are better.	12.1%	3.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication Lower percentages are better.	9.2%	16.2%
Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine Higher percentages are better.	99.6%	96.7%
Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine Higher percentages are better.	99.0%	94.1%
Percent of long-stay residents who received an antipsychotic medication Lower percentages are better.	7.2%	12.4%

5 Inspection Summary

Date of standard health inspection: 03/14/2019
Total number of health deficiencies: 18
Average number of health deficiencies in Maryland: 14.9