Clinton Gardens

In the surveyor’s words

From the most serious findings on record at Clinton Gardens, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jun 6, 2023

  Based on observation, interview, and record review, the facility failed to ensure proper food handling for 1 of 2 dining observations and failed to ensure proper handwashing for 3 of 3 dining observations. Findings include: 1. During a dining observation, on 5/30/23 at 11:32 a.m., Activity Assistant 14 was preparing drinks for the residents. She scooped ice into 2 glasses and returned the scoop into the ice bucket. The Activity Assistant served the drinks to 2 residents and returned to the cart to prepare more drinks. At 11:41 a.m., the ice scoop remained in the ice bucket. At 11:43 a.m., another staff member approached the ice bucket and placed the ice scoop into an empty pitcher next to the ice bucket. […]

• No harm, potential for more than minimal, patternF888Mar 18, 2022

  Based on observation, interview, and record review, the facility failed to ensure the COVID-19 Infection Control vaccination policy and procedures were followed for 7 of 7 contracted staff working in the facility near residents for 6 of 6 days working in the facility. Findings include: On 3/11/22 at 9:50 a.m., during the initial tour of the facility, contractors, wearing medical face masks, were present in the C-wing unit, observed replacing the cove base and lower wall covering in the hall. On 3/11/22 at 10:37 a.m., during the initial tour of the memory care unit, contractors were present in the unit observed replacing the cove base and the lower wall covering. […]

• No harm, potential for more than minimal, isolatedF697Aug 11, 2025

  Based on observation, record review, and interview, the facility failed to ensure a resident had effective pain management for 1 of 2 residents reviewed for pain management (Resident 43). Findings include:On 8/05/2025 at 2:42 p.m., during an interview, Resident (43) indicated she received pain medication twice daily and indicated it was not helping to control her pain. The resident had asked for an increase in pain medication but was told she could not have more. She indicated they did administer Tylenol, but it was not effective. The resident demonstrated physical signs of pain during interview. On 8/08/2025 at 9:39 a.m., the medical record of Resident 43 was reviewed. The resident was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, isolatedF760Aug 11, 2025

  Based on record review and interview, the facility failed to administer medication according to physician orders and held medications without a physician order for 1 of 5 residents reviewed for unnecessary medications (Resident 6). Findings include:On 8/7/25 at 11:00 a.m., the medical record of Resident 6 was reviewed. The resident was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Cerebral Vascular Accident (CVA) (stroke), dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high).A physician order, dated 7/16/25, indicated to administer insulin… […]

• No harm, potential for more than minimal, isolatedF761Aug 11, 2025

  Based on observation, record review, and interview, the facility failed to ensure a medication prescription label matched the physician's order for 1 of 35 medication administrations observed (Resident 28). Findings include:On 8/8/25 at 8:47 a.m. Qualified Medication Aide (QMA) 9 administered mirtazapine (antidepressant) 15 milligrams (mg), 2 tablets to Resident 28. The label on the mirtazapine medication card, dated 7/8/25, indicated mirtazapine 15 mg, 1 tablet by mouth daily. There was no directions changed sticker or indication that two tablets were ordered. At the same time, QMA 9 indicated the medication order was changed to two tablets on 8/4/25. Resident 28's record was reviewed on 8/8/25 at 2:39 p.m. […]