Clinton Place

In the surveyor’s words

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

• Actual harm, isolatedF684Jun 28, 2024

  Based on observation, record review, interviews, and facility policy review it was determined that the facility failed to provide quality of care related to skin impairment and Activities of Daily Living for one of 33 sampled residents. (Resident #45 (R45)). On 07/15/2023 at 12:44 AM, nursing observed small white insects approximately 3 cm [centimeters] in size what appeared to look like small worms, in creases of resident's wound beds on both lower extremities. The resident had a temp of 101.6 and was complaining of chills and sweats. Resident 45 was sent to the emergency room for evaluation. […]

• No harm, potential for more than minimal, widespreadF925Jun 28, 2024

  Based on observation, interviews, record review, and review of the facility's policy it was determined the facility failed to maintain an effective pest control program to ensure it was free of pests. All 81 residents had the potential to be affected. On 07/15/2023, 06/01/2024, and 06/02/2024, Resident (R) 45 was found to have maggots in her skin folds and bilateral lower extremity wound beds. Observation on 06/27/2024 at 1:42 PM revealed flies in R45's room with one fly on the resident's face and one fly on the left side of the resident's neck. Refer to F684. The findings include: Review of the facility's policy titled, Resident Rights, revised 03/18/2024, revealed the resident had a right to a safe, clean, comfortable and home like environment. […]

• No harm, potential for more than minimal, isolatedF550Aug 29, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents' rights were protected related to meal service for 2 residents out of the 20 sampled residents, (Resident (R)70 and R81).The findings include: Review of the facility policy titled, Resident Rights, dated 01/02/2020, revealed residents had the right to be treated with respect and dignity, including the right to a dignified existence, self-determination, and access to services inside the facility. Observation of the dining service on 08/27/2025 at 11:35 AM, revealed staff were serving the first table with all residents served their meals except R81. Per observation, staff moved to serve residents at the second table before serving R81 the meal. […]

• No harm, potential for more than minimal, isolatedF761Aug 29, 2025

  Based on observation, interview, and facility policy review, the facility failed to store medication in accordance with accepted standards of practice, which had the potential to affect 83 out of 83 facility residents. The findings include: Observation of the facility's Long Hall medication storage room on 08/28/2025 at 9:00 AM revealed seven tablets of Ondansetron (Zofran) 4 milligrams (mg) in a blister pack, not labeled with a resident's name, and with no expiration date on it. Further observation revealed that the Ondansetron was located in a plastic bin containing miscellaneous items, such as a flashlight and a toothpaste tube, stored above the sink. […]

• No harm, potential for more than minimal, isolatedF812Aug 29, 2025

  Based on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect 20 of the facility's 83 residents. The findings include: Review of the facility policy titled, Food Safety Requirements reviewed 06/2025, revealed the facility was to store food in accordance with professional standards for food service safety. Further review revealed refrigerated items should include labeling and dating of the food items, so it was used by its use-by date. […]