The resident, identified as R45 in inspection documents, told inspectors on June 27 that she "did not like the flies on her and that they made her feel bad." She also reported finding maggots on her legs at least twice.
Clinton Place's own pest control logs documented the scope of the problem in the weeks before the June inspection. On a single day — June 1 — staff killed 45 flies across multiple locations: 10 in R45's room at 10 a.m., 15 at the nurse's station an hour later, 10 more in another resident's room that afternoon, and 10 in a different resident's room that morning.
The facility's pest sighting log showed staff had been tracking and killing flies throughout May and June. Twenty flies were found and killed at the nurse's station on May 21. Twelve flies were spotted in the employee breakroom and bathroom on May 27, though only four were killed.
During the federal inspection, the problems were visible throughout the building. On June 23, inspectors observed four flies swarming in the 200 Hall and dining room area at 6:10 p.m. Twenty-three minutes later, four more flies were swarming in resident R37's room, with one landing on the resident's arm and another on the bed.
The next day brought similar scenes. Inspectors found three flies in R45's room at 2:28 p.m., including one on her bed. By June 25, three flies were swarming in the 200 Hall again.
The worst observation came on June 26. At 1:27 p.m., inspectors found three flies resting near R45's thigh, with five additional flies swarming over her bed. Nursing staff were observed waving their hands to shoo the flies away from the resident.
R45, who has been at Clinton Place since December 2020, scored 14 out of 15 on a cognitive assessment in April, indicating she was mentally intact and fully aware of her surroundings. Her diagnoses include lymphedema and intellectual disabilities.
State Registered Nurse Aide 4 confirmed the scope of the problem during an interview on June 26. "The flies were a problem all over the facility," she told inspectors.
Another aide, SRNA6, said she had "seen numerous flies throughout the facility and that they seem to be a persistent problem."
Registered Nurse 4 described the facility's response efforts during a June 27 interview. The facility had distributed fly swatters and installed pest control light stations, though she couldn't recall when these measures were implemented. She said maintenance had been working on the problem and that fly sightings were being logged at the nurse's station.
"She felt there was more the facility could do to help get rid of the flies," the inspection report noted. The nurse said she last saw the pest control company at the facility about a month earlier.
The facility's maintenance director, who had been in the position since September 2023, acknowledged the severity of the situation during a June 27 interview. He said the current pest control company had always been the provider and that no consideration had been given to seeking alternatives.
"This year had been a rough year for pest control in general, and ever since spring hit this year the pest control became an issue," he told inspectors. He said they had not located where the flies were entering the building.
His solutions included providing fly swatters and ensuring windows were screened.
Administrator interviews on June 28 revealed additional measures the facility had attempted. They had placed fly lights specifically in R45's room, distributed fly swatters, installed air blowers over some exit doors, and tried to keep windows closed. The administrator said she had to educate R45 about keeping her windows shut.
She expressed satisfaction with the current pest control company, calling them "the best company thus far." The administrator said monthly pest control visits were occurring and that the facility was "working on adding more blowers to the outside to help control them and keep them away from the entrances."
The administrator attributed the problem partly to location, saying it was "difficult because they were out in the middle of fields and located next to a creek bed, where the pests just tend to be in abundance."
Review of pest control service reports from January through June 2024 showed monthly treatments of the facility's exterior perimeter and entry points. However, the reports listed only "general services" without specifying the type of treatment provided.
When state surveyors attempted to contact the pest control company on June 25 and again on June 27, they received no response or return call.
Clinton Place's own policies required maintaining a "safe, clean, comfortable and home like environment" for residents and keeping the building "free of insects and rodents" through an effective pest control program.
The federal citation for failing to provide a sanitary environment affected many residents and carried a designation of "minimal harm or potential for actual harm."
R45 continues to live with the daily reality of the infestation, her complaints about flies making her "feel bad" documented in federal records alongside her reports of finding maggots on her body.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clinton Place from 2024-06-28 including all violations, facility responses, and corrective action plans.