Deficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 4
Date: Aug 11, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication management, pain management, immunizations, and medication labeling in the nursing home.
Findings
The facility was found deficient in providing effective pain management, administering medications according to physician orders, ensuring proper medication labeling, and offering influenza vaccinations. Deficiencies included failure to provide prescribed pain medication timely, holding insulin without physician orders, medication label discrepancies, and lack of documentation for influenza vaccine administration or contraindications.
Deficiencies (4)
F 0697: The facility failed to provide safe and appropriate pain management for a resident, including failure to administer prescribed oxycodone and lack of documentation of pain scale ratings and physician notifications.
F 0760: The facility failed to administer medications according to physician orders and held insulin without physician orders for a resident, lacking documentation of refusal interventions and physician notifications.
F 0761: The facility failed to ensure medication prescription labels matched physician orders for a medication administered to a resident, resulting in administration of incorrect dosage.
F 0883: The facility failed to develop and implement policies and procedures to ensure influenza vaccination was offered or administered to a resident, with no documentation of vaccine offer, refusal, or clinical contraindication.
Report Facts
Medication refusals: 39
Medications held: 46
Medications held: 10
Medications refused: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) 7 | Interviewed regarding pain medication notification and physician communication for Resident 43. | |
| Director of Nursing (DON) | Interviewed regarding pain medication administration and documentation issues. | |
| Unit Manager | Interviewed about medication refusal notification procedures for Resident 6. | |
| Licensed Practical Nurse (LPN) 3 | Interviewed about insulin refusal notification and holding procedures. | |
| Qualified Medication Aide (QMA) 4 | Interviewed about medication refusal documentation and notification. | |
| Qualified Medication Aide (QMA) 9 | Observed administering medication and interviewed about medication label discrepancies. | |
| Director of Nursing Services (DNS) | Interviewed about influenza vaccination administration and resident condition. | |
| Administrator | Provided facility policies related to pain management, medication shortages, medication order changes, and influenza vaccination. | |
| Resident's Physician | Interviewed by phone regarding medication refusals and orders for Resident 6. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 10, 2025
Visit Reason
The inspection was conducted in response to a complaint (IN00460788) regarding medication administration practices at the facility.
Complaint Details
This citation relates to Complaint IN00460788.
Findings
The facility failed to ensure a physician-ordered nicotine patch was administered and documented appropriately for one resident. The medication was documented as given at the wrong time, and there were discrepancies in the medication count indicating some patches were unaccounted for.
Deficiencies (1)
F 0755: The facility failed to ensure a physician-ordered nicotine patch was administered and documented appropriately for one resident. The patch was documented as given at 10:44 a.m. but was actually applied at 1:40 p.m., and medication counts did not match administration records.
Report Facts
Medication patches shipped: 30
Medication patches remaining: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 3 | Administered nicotine patch late and documented incorrect administration time | |
| QMA 6 | Completed medication count for nicotine patches | |
| DON | Director of Nursing | Interviewed regarding medication administration and documentation |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 1
Date: Jun 9, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00460697, IN00460788, and IN00461234 at Clinton Gardens.
Complaint Details
Complaint IN00460697 and IN00461234 had no deficiencies related to the allegations. Complaint IN00460788 was substantiated with federal/state deficiencies cited at F755 related to medication administration.
Findings
The facility failed to ensure a physician-ordered medication, specifically a nicotine patch, was administered and documented appropriately for 1 of 3 residents reviewed. Deficiencies related to complaint IN00460788 were cited, while no deficiencies were found for the other complaints.
Deficiencies (1)
Failure to ensure a physician ordered nicotine patch was administered and documented appropriately for Resident B.
Report Facts
Census: 71
Total Capacity: 71
Medicare residents: 3
Medicaid residents: 45
Other payor residents: 23
Nicotine patches shipped: 30
Nicotine patches remaining: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Brewer | Executive Director | Signed the report as facility representative |
| QMA 3 | Interviewed regarding failure to administer nicotine patch and documentation errors | |
| QMA 6 | Assisted with medication count for Resident B's nicotine patches | |
| DON | Director of Nursing | Interviewed regarding medication administration and documentation practices |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Date: Apr 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456102.
Complaint Details
Complaint IN00456102 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 6
Medicaid census: 48
Other census: 16
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 0
Date: Feb 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452882.
Complaint Details
Complaint IN00452882 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census SNF/NF beds: 72
Total census: 72
Medicare census: 4
Medicaid census: 44
Other payor census: 24
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Date: Nov 1, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00442505 and IN00445067.
Complaint Details
Complaint IN00442505 - No deficiencies related to the allegations are cited. Complaint IN00445067 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00442505 and IN00445067 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF beds: 66
Total census: 66
Medicare census: 4
Medicaid census: 45
Other payor census: 17
Inspection Report
Re-Inspection
Census: 70
Capacity: 100
Deficiencies: 0
Date: Oct 7, 2024
Visit Reason
A Post Survey Revisit to the Life Safety Code Recertification and State Licensure Survey conducted on 08/29/24 by the Indiana Department of Health.
Findings
Clinton Gardens was found in compliance with Requirements for Participation in Medicare, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered and had appropriate fire alarm and emergency generator systems.
Report Facts
Facility capacity: 100
Census: 70
Inspection Report
Life Safety
Census: 67
Capacity: 100
Deficiencies: 1
Date: Aug 29, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a), respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to improper disposal of cigarette butts in the designated staff smoking area. The cigarette butts were cleaned up and education was provided to staff regarding safe smoking practices.
Deficiencies (1)
Failed to ensure cigarette butts were properly disposed of at the staff smoking area, with over 10 cigarette butts found on the ground around the table by the generator.
Report Facts
Facility capacity: 100
Census: 67
Number of cigarette butts observed: 10
Staff potentially affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Brewer | Executive Director | Signed the report |
| Maintenance Director | Interviewed regarding cigarette butt disposal deficiency |
Inspection Report
Renewal
Census: 64
Capacity: 64
Deficiencies: 4
Date: Aug 16, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 12 to August 16, 2024.
Findings
The facility was found deficient in several areas including failure to complete self-administration medication assessments, untimely care plan meetings for residents, improper wound care by Qualified Medication Aides, and medication storage violations including presence of personal drinks and expired medications.
Deficiencies (4)
Failure to ensure a self-administration assessment had been completed for a resident observed self-administering medications.
Failure to ensure care plan meetings were completed timely for 2 of 24 residents reviewed.
Qualified Medication Aide failed to follow proper standards of practice for pressure ulcer care.
Medication storage areas contained personal drinks and expired medication was not disposed of properly.
Report Facts
Survey dates: 5
Census: 64
Total capacity: 64
Residents reviewed for care plan meetings: 24
Days QMA documented dressing changes: 4
Pressure ulcers: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Brewer | Executive Director | Signed the report |
| LPN 16 | Licensed Practical Nurse | Interviewed regarding medication storage and medication administration |
| LPN 10 | Licensed Practical Nurse | Interviewed regarding expired eye drops and medication administration |
| QMA 3 | Qualified Medication Aide | Interviewed regarding wound care and dressing changes |
| QMA 7 | Qualified Medication Aide | Interviewed regarding scope of practice for dressing changes |
| Director of Nursing | Director of Nursing | Interviewed regarding medication self-administration and wound care policies |
| Social Services Director | Social Services Director | Interviewed regarding care plan meetings documentation |
| Administrator | Administrator | Interviewed regarding care plan meetings and medication storage policies |
| Assistant Director of Nursing | Assistant Director of Nursing | Observed wound dressing changes and interviewed regarding dressing documentation |
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 16, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on August 16, 2024.
Findings
Clinton Gardens was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Routine
Deficiencies: 4
Date: Aug 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to medication self-administration, care plan meetings, pressure ulcer care, and medication storage in the nursing facility.
Findings
The facility failed to ensure proper assessment and documentation for resident self-administration of medications, timely completion of care plan meetings for residents, adherence to professional standards in pressure ulcer care by Qualified Medication Aides, and proper medication storage including removal of expired medications and prohibition of personal drinks in medication carts.
Deficiencies (4)
F 0554: The facility failed to ensure a self-administration assessment was completed for a resident observed self-administering medications without supervision or physician order.
F 0657: The facility failed to ensure care plan meetings were completed timely for 2 of 24 residents reviewed, lacking documentation of quarterly meetings.
F 0658: The facility failed to ensure the Qualified Medication Aide followed proper standards of practice for pressure ulcer care, including inappropriate dressing changes on stage 3 and unstageable wounds.
F 0761: The facility failed to ensure medication storage areas were free from personal drinks and expired medications were disposed of properly for 2 of 4 medication carts reviewed.
Report Facts
Residents reviewed for care plan meetings: 24
Residents affected by care plan meeting deficiency: 2
Days QMA documented dressing changes: 4
Medication carts reviewed: 4
Medication carts with deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 16 | Licensed Practical Nurse | Interviewed regarding medication storage and supervision of medication administration |
| Director of Nursing | Director of Nursing | Interviewed regarding medication self-administration policy and QMA dressing change practices |
| Licensed Practical Nurse 10 | Licensed Practical Nurse | Interviewed regarding expired eye drops and medication administration |
| Assistant Director of Nursing | Assistant Director of Nursing | Observed dressing changes and interviewed regarding dressing labeling |
| Qualified Medication Aide 3 | Qualified Medication Aide | Interviewed regarding pressure ulcer dressing changes and documentation |
| Qualified Medication Aide 7 | Qualified Medication Aide | Interviewed regarding scope of practice for dressing changes |
| Social Service Director | Social Service Director | Interviewed regarding care plan meeting documentation |
| Administrator | Administrator | Interviewed regarding care plan meetings and medication storage policies |
| Licensed Practical Nurse 17 | Licensed Practical Nurse | Interviewed regarding medication administration supervision |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00434905, IN00431675, and IN00430530 at Clinton Gardens.
Complaint Details
Complaints IN00434905, IN00431675, and IN00430530 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00434905, IN00431675, and IN00430530 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF beds: 65
Total census: 65
Medicare census: 4
Medicaid census: 43
Other payor census: 18
Inspection Report
Re-Inspection
Census: 66
Capacity: 100
Deficiencies: 0
Date: Jul 25, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/20/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
Clinton Gardens was found in compliance with Medicare participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered and equipped with appropriate fire alarm and emergency generator systems.
Report Facts
Facility capacity: 100
Census: 66
Inspection Report
Life Safety
Census: 66
Capacity: 100
Deficiencies: 1
Date: Jun 20, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 06/20/2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to a deficiency involving the heating device in the laundry room. Specifically, the fuel-fired dryers' fresh air intake was almost fully covered, obstructing combustion air from outside, which could create a hazardous atmosphere.
Deficiencies (1)
The facility failed to ensure 1 of 1 laundry rooms was provided with intake combustion air from the outside for rooms containing fuel fired equipment, as the fresh air intake was almost fully covered with plywood and lint.
Report Facts
Facility capacity: 100
Census: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Brewer | Executive Director | Named in relation to review of findings at exit conference |
| Maintenance Director | Interviewed regarding the deficiency with the heating device air intake |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 6, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident rights, activities of daily living, skin care, catheter care, medication management, and food handling.
Findings
The facility was found deficient in multiple areas including failure to address residents' dignity in communication, incomplete assistance with activities of daily living, inadequate documentation and reporting of a resident's skin injury, improper catheter care procedures, failure to implement pharmacy recommendations for unnecessary medications, and improper food handling and hand hygiene practices.
Deficiencies (6)
F 0550: The facility failed to ensure residents were addressed in a dignified manner for 3 of 3 residents reviewed, with staff using an inappropriate name 'Mama' without care plan indication.
F 0677: The facility failed to ensure activities of daily living were completed for 4 of 24 residents, including failure to provide shaving and nail care as required.
F 0684: The facility failed to document, report, and address a skin condition on a resident, with a bruise-like discoloration from bumping head on a Hoyer lift not properly documented or reported.
F 0690: The facility failed to ensure proper catheter care for 1 resident, including allowing the urinary catheter drainage bag to touch the floor and improper procedure when changing urinary drainage leg bags.
F 0757: The facility failed to ensure pharmacy recommendations were addressed and initiated for 2 of 5 residents reviewed for unnecessary medications, including failure to initiate gastroprotection medication.
F 0812: The facility failed to ensure proper food handling for 1 of 2 dining observations and proper handwashing for 3 of 3 dining observations, including improper ice scoop storage and staff touching faucet handles with bare hands.
Report Facts
Residents reviewed for ADL care: 24
Residents reviewed for skin conditions: 24
Residents reviewed for catheter care: 1
Residents reviewed for unnecessary medications: 5
Dining observations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Assistant 5 | Named in dignity deficiency for addressing residents improperly | |
| Certified Nursing Assistant 12 | CNA | Named in ADL deficiency related to failure to remove chin hair |
| Certified Nursing Assistant 15 | CNA | Named in ADL deficiency related to nail care |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including dignity, skin injury, catheter care, and medication management |
| Executive Director | ED | Provided facility policies and interviewed regarding deficiencies |
| Certified Nurse Aide 3 | CNA | Observed improperly changing urinary drainage bag |
| Certified Nursing Aid 4 | CNA | Observed improper handwashing technique |
| Culinary Manager | Interviewed regarding food handling and hand hygiene deficiencies | |
| Licensed Practical Nurse 9 | LPN | Provided information about resident's skin injury |
| Registered Nurse 17 | RN | Observed resident's fingernails and commented on care |
Inspection Report
Annual Inspection
Census: 64
Capacity: 64
Deficiencies: 6
Date: Jun 6, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00405733.
Complaint Details
Complaint IN00405733 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in multiple areas including resident dignity, activities of daily living care, skin condition documentation, catheter care, medication management, and food safety practices. Complaint allegations were not substantiated. Corrective actions and staff education were implemented for all deficiencies.
Deficiencies (6)
Facility failed to ensure residents were addressed in a dignified manner for 3 residents.
Facility failed to ensure Activities of Daily Living (ADL) care were completed for 4 residents.
Facility failed to document, report, and address a skin condition on a resident.
Facility failed to ensure a resident's urinary catheter drainage bag did not touch the floor and proper procedure was followed when changing drainage bags.
Facility failed to ensure pharmacy recommendations were addressed and initiated for 2 residents.
Facility failed to ensure proper food handling and handwashing during dining observations.
Report Facts
Census: 64
Total Capacity: 64
Pharmacy Recommendations: 2
Residents reviewed for ADL care: 24
Residents with ADL deficiencies: 4
Residents reviewed for dignity: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Brewer | Executive Director | Signed report and involved in policy review |
| Dementia Care Director | Interviewed regarding resident addressing practices | |
| Certified Nursing Assistant 12 | CNA | Interviewed regarding ADL care for Resident 57 |
| Certified Nursing Assistant 15 | CNA | Interviewed regarding ADL care for Resident 15 |
| Certified Nursing Assistant 7 | CNA | Interviewed regarding nail care responsibilities |
| Licensed Practical Nurse 9 | LPN | Provided information about skin injury incident |
| Certified Nurse Aide 3 | CNA | Observed and interviewed regarding catheter care |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies and policies |
| Executive Director | ED | Interviewed and provided facility policies |
| Culinary Manager | Interviewed regarding food handling and handwashing |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on June 6, 2023.
Findings
Clinton Gardens was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 58
Capacity: 58
Deficiencies: 0
Date: Aug 9, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00384800.
Complaint Details
Complaint IN00384800 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
Clinton Gardens was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation of Complaint IN00384800. The complaint was unsubstantiated due to lack of evidence.
Report Facts
Census: 58
Total Capacity: 58
Medicare Residents: 5
Medicaid Residents: 42
Other Payor Residents: 11
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