Clinton Place

F-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.

Review of the facility's policy titled, Pest Control, revised 03/23/2024, revealed the facility shall maintain an effective, on-going pest control program that ensures the building is kept free of insects and rodents.

Review of the facility's policy titled, Maintenance Service, revised 09/20/2023, revealed maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.

Review of the facility's Pest Control Monthly Service Report's dated 01/24/2024 at 11:30 AM, 02/22/2024 at 11:30 AM, 03/28/2024 at 12:35 PM, 04/24/2024 at 12:00 PM, 05/23/2024 at 1:40 PM, and 06/21/2024 at 12:20 PM, revealed the pest control company treated the facility's exterior perimeter and points of entry. Further review service reports revealed it was for general services, but did not list the specific type of treatment provided.

Review of the facility's document titled, Pest Sighting Log, not dated, revealed on 05/21/2024 at 9:00 AM, twenty flies were found and killed at the 200 Hall nurse's station and ten flies were found and killed in Resident R45's room. On 05/27/2024 at 10:00 AM twelve flies were found in the employee breakroom and bathroom but only four were killed. On 06/01/2024 at 10:00 AM, ten flies were found and killed in Resident R45's room. On 06/01/2024 at 11:00 AM, 15 flies were found and killed at the 200 Hall Nurse Station. On 06/01/2024 at 1:00 PM 10 flies were found and killed in the room of Resident (R) 63. On 06/01/2024 at 7:00 AM, 10 flies were found and killed in Resident R4's room . On 06/02/2024 at 2:00 PM, 10 flies were found and killed at the Nurse Station on 200 Hall. On 06/02/2024 at 6:00 PM, eight flies were found and killed in the room of Resident R37. On 06/02/2024 at 6:00 PM, four flies were found and killed in the room of Resident R63. On 06/09/2024 at 10:45 AM, three flies were found and killed in the room of Resident R53.

On 06/23/2024 at 6:10 PM, observation revealed four flies swarming on the 200 Hall and dining room area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 185469 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185469 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Clinton Place 106 Padgett Drive Clinton, KY 42031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 On 06/23/2024 at 6:23 PM, observation revealed four flies swarming in Resident (R) 37's room and one fly landing on resident's arm and another one landing on the resident's bed. Level of Harm - Minimal harm or potential for actual harm On 06/24/2024 at 2:28 PM, observation revealed three flies in Resident R45's room and one (1) on the resident's bed.

Residents Affected - Many On 06/25/2024 at 10:00 AM, observation revealed three flies swarming on the 200 Hall of the facility.

Observation on 06/26/2024 at 1:27 PM revealed flies in Resident R45's room with three (3) flies resting near the resident's thigh. Also, five (5) additional flies were noted swarming over the resident's bed. Nursing staff was observed to be waving their hands to shoo the flies away.

On 06/26/2024 at 1:40 PM, observation revealed four (4) flies swarming around Hall 200 and in and out of multiple residents' rooms. During an interview with State Registered Nurse Aide (SRNA) 4, at this time, she stated the flies were a problem all over the facility.

Observation on 06/27/2024 at 1:42 PM revealed flies in Resident R45's room with one fly on the resident's face and one fly on the left side of the resident's neck. During an interview with Resident R45, at this time, she stated that she did not like the flies on her and that they made her feel bad.

Record review revealed the facility admitted Resident R45 on 12/16/2020 with diagnoses to include [NAME]-[NAME] Syndrome, Lymphedema, and Unspecified Intellectual Disabilities.

Review of Resident R45's Quarterly Minimum Data Set Assessment with an Assessment Reference Date (ARD) of 04/08/2024 revealed the facility assessed Resident R45 to have a Brief Interview for Mental Status (BIMS) Score of fourteen (14) out of fifteen (15). This score indicated the resident was cognitively intact.

In an interview with Resident R45 on 06/24/2024 at 2:28 PM, she stated that she has had lots of flies in her room at times, and had maggots on her legs at least two (2) times.

In an interview with SRNA6 on 06/26/2024 at 2:45 PM, she stated she has seen numerous flies throughout

the facility and that they seem to be a persistent problem.

During an interview with SRNA4 on 06/26/2024 at 1:40 PM, she stated the flies were a problem all over the facility.

In an interview with Registered Nurse (RN) 4 on 06/27/2024 at 2:10 PM, she stated they have logged pest sightings on the pest control logbook that was located at the nurse's station. She stated they also reported

the fly problem to Maintenance and they appeared to have been working on it. She stated the facility gave out fly swatters, and put up pest control light stations to try and combat the flies. RN4 stated she couldn't recall when these measures were put in place. She stated she felt there was more the facility could do to help get rid of the flies. She stated she last saw pest control at the facility about a month ago.

The State Survey Agency (SSA) surveyor contacted the facility's Pest Control Company on 06/25/2024 at 9:40 AM and on 06/27/2024 at 3:55 PM, with no response or return call.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 185469 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185469 B. Wing 06/28/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Clinton Place 106 Padgett Drive Clinton, KY 42031

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 In an interview with the facility's Maintenance Director on 06/27/2024 at 3:17 PM, he stated he had been the maintenance director since 09/2023. He stated that the current pest control company had always been the Level of Harm - Minimal harm or pest control provider and there had not been any considerations made by him or administration to seek other potential for actual harm pest control companies. He stated that the current company was doing ok. He stated 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. Residents Affected - Many He further stated they had not located a point of entry for the flies. The Maintenance Director further stated

he provided fly swatters, and made sure the windows were screened.

In an interview with the Administrator on 06/28/2024 at 1:23 PM, she stated that they have pest control come monthly. She stated they had also, placed fly lights in Resident R45's room, given out fly swatters, placed air blowers over some of the exit doors, and tried to keep the windows shut. The Administrator stated she had to educate Resident R45 on keeping the windows shut. She stated she had no issues with the current pest control company and thought they had been the best company thus far. The Administrator stated she felt that they had done the best they could to control the flies in the facility. She stated they were working on adding more blowers to the outside to help control them and keep them away from the entrances. The Administrator further stated 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 185469