Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clinton Gardens during CMS and state inspections, most recent first.
Failure to provide effective pain management for a resident with a right femur fracture. The resident reported that BID pain meds were not helping, Tylenol was ineffective, and she continued to show signs of pain. The chart lacked a pain care plan, the ordered oxycodone was not administered when unavailable, physician notification was not documented, and several MAR entries for Tylenol and Tramadol lacked follow-up pain scale documentation to show effectiveness.
Insulin was not administered as ordered for a resident with CVA, dementia, and type 2 DM. EMAR review showed repeated insulin refusals and multiple instances where scheduled and sliding-scale insulin were held without a physician order, and the chart lacked documentation that the MD was notified. Staff interviews showed mixed practices about when to notify the physician, while the physician confirmed she had not ordered insulin to be held if the resident did not eat or had a change in condition.
Medication Label Did Not Match Order: A resident with moderate cognitive impairment received mirtazapine 15 mg, 2 tabs even though the med card label still showed 15 mg, 1 tab daily. Staff stated the order had changed, but there was no directions-changed sticker or other indication on the card, and the resident's record showed multiple recent mirtazapine order changes for appetite stimulation.
A resident’s record lacked documentation that the influenza vaccine was offered, declined, or clinically contraindicated during flu season. The preventative health care record noted the vaccine was not given because the resident was transferred to the hospital, and the DON stated the resident had repeated hospitalizations with nausea and vomiting, but there was no supporting documentation in the chart.
A resident with multiple medical conditions did not receive a physician-ordered nicotine patch as prescribed on several occasions. The patch was documented as administered before it was actually applied, and a medication count revealed discrepancies between the number of patches used and those documented in the eMAR. Facility policy requiring post-administration documentation was not followed, leading to inaccurate records.
A resident was observed self-administering medications without supervision, and the facility failed to complete a required self-administration assessment. The resident, with diagnoses including hypertension and heart failure, was taking medications such as a diuretic and an antiplatelet. Interviews revealed that some nurses left medications for the resident to take later, contrary to facility policy requiring supervision and a physician's order for self-administration.
The facility failed to conduct timely care plan meetings for two residents, resulting in missing documentation for significant periods. One resident, cognitively intact, reported not having a care plan meeting in three years, while another with moderate cognitive impairment had no records of quarterly meetings for several months. The Social Services Director admitted to documentation lapses, and the Administrator confirmed the lack of evidence for required meetings.
A QMA at the facility improperly documented and performed dressing changes on a resident's advanced pressure ulcers, contrary to facility policy which restricts QMAs to Stage I wound care. The resident had multiple pressure ulcers, and the QMA's actions were not in line with the standards of practice, as confirmed by the DON. Observations also noted that dressings were not properly dated or initialed, further indicating a lapse in adherence to care protocols.
The facility failed to ensure proper medication storage and disposal practices. An LPN stored a personal drink in a medication cart, and expired latanoprost eyedrops were administered to a resident beyond the recommended usage period. The facility's policy on medication storage and expiration was not followed, as expired medications were not stored separately until destruction or return to the pharmacy.
Failure to Provide Effective Pain Management
Penalty
Summary
Safe, appropriate pain management was not provided for a resident admitted with a displaced intertrochanteric fracture of the right femur, CHF, and diabetes. The resident was cognitively intact, required extensive assistance with daily care, and told staff that the pain medication she was receiving twice daily was not helping to control her pain. During interview, she stated she had asked for an increase in pain medication but was told she could not have more, and she demonstrated physical signs of pain. The record showed that a 48-hour admission care plan and comprehensive care plan lacked documentation for pain management. An order for oxycodone 5 mg BID was entered on 7/26/25 and discontinued on 7/29/25, but the July 2025 MAR showed the medication was not administered from 7/26/25 through 7/28/25 because it was not available. The record lacked documentation that the physician was notified of the increased pain or of the medication being unavailable before 7/28/25. A nurse note on 7/28/25 documented moderate right leg pain and that Tylenol had no relief, and noted the resident had an oxycodone order that was not active in house. Subsequent pain medication administration records showed Tylenol and then Tramadol were given for ongoing right leg pain, but several entries lacked follow-up pain scale ratings to show whether the medication was effective. The resident continued to frequently state she had right leg pain, and a nurse later documented that she took Tramadol twice daily with Tylenol in between and was pending further orders. During interview, RN 7 stated she would obtain narcotics from the EDK or call the on-call physician if needed, and acknowledged she had notified the physician about the resident's increased pain but had not documented it. The DON stated she did not know why oxycodone was not administered or why the pain documentation lacked follow-up pain scales.
Insulin Held Without Physician Order
Penalty
Summary
The facility failed to administer insulin according to physician orders and held insulin without a physician order for Resident 6, who had diagnoses including CVA, dementia, and type 2 diabetes. The resident’s record showed orders for insulin glargine 10 units twice daily and lispro insulin 8 units four times daily, along with a sliding scale lispro order. Review of the EMAR showed the resident’s insulin was refused numerous times and was also held multiple times during July and early August 2025. The physician orders did not include documentation authorizing insulin to be held, and each EMAR entry provided for physician notification indicated the physician was not notified. The resident’s quarterly MDS indicated severe cognitive impairment, and the resident was receiving daily insulin and other high-risk medications, including an anticoagulant and a diuretic. The care plan identified the resident as at risk for adverse effects related to glucose-lowering medication and diabetes, with interventions for diet, blood sugar monitoring, documentation of abnormal findings, and physician notification. However, the care plan lacked documentation of medication refusal or interventions. During interviews, the Unit Manager, LPN, and QMA described notifying the physician when medications were refused, and the DON stated the physician was aware of the frequent refusals. The physician confirmed awareness of the refusals but stated she had not ordered insulin to be held if the resident did not eat or if there was a change in condition, and the facility could not provide a policy for notification of refusal or parameters for holding medications.
Medication Label Did Not Match Physician Order
Penalty
Summary
The facility failed to ensure a medication prescription label matched the physician's order for 1 of 35 medication administrations observed for a resident with moderate cognitive impairment who was receiving an antidepressant during the assessment look-back period. On 8/8/25 at 8:47 a.m., a QMA administered mirtazapine 15 mg, 2 tablets, to the resident, but 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 other indication that two tablets had been ordered. At the time of the observation, the QMA stated the medication order had been changed to two tablets on 8/4/25. The resident's record showed prior mirtazapine orders of 15 mg daily, then 7.5 mg daily, and then an order dated 8/4/25 for mirtazapine 30 mg by mouth once daily for appetite stimulation. During interview, another QMA stated that when a medication order is changed and the medication card differs from the physician's order, a directions changed sticker should be placed on the card and the old card should be removed when the new medication card arrives. The facility policy provided by the Administrator stated that changed orders should be treated as new orders with cancellation of the previous order and that a 'Change in Directions' sticker should be attached until the pharmacy permanently affixes the new label.
Influenza Vaccine Not Documented as Offered or Contraindicated
Penalty
Summary
The facility failed to ensure an influenza vaccination was offered or administered to 1 of 5 residents reviewed for immunizations. Resident 1's record showed multiple hospitalizations during the flu season, and the preventative health care record dated 10/31/24 indicated the influenza vaccine was not administered because the resident was transferred to the hospital for further evaluation. However, the record lacked any further documentation about the influenza vaccine, and progress notes from September 2024 through December 2024 did not document that the vaccine was offered, declined, or clinically contraindicated. During interview, the DNS stated the resident was not given the influenza vaccine because of her condition and because she had been hospitalized several times with nausea and vomiting, but acknowledged there was no documentation in the record to support that the vaccine was clinically contraindicated.
Failure to Administer and Document Physician-Ordered Medication as Prescribed
Penalty
Summary
A deficiency occurred when a resident with a history of a right hip fracture, chronic obstructive pulmonary disease, and adjustment disorder did not consistently receive a physician-ordered nicotine patch as prescribed. The resident reported missing the nicotine patch for several days, and on the day of the survey, the patch was not applied during the scheduled medication pass because the resident was in therapy. The Qualified Medication Aide (QMA) responsible for administering the medication documented the patch as given at 10:44 a.m., despite not having applied it until approximately 1:40 p.m. after being reminded by the resident. The electronic medication administration record (eMAR) reflected the patch as administered at the earlier time, not the actual time of application. A review of the medication count revealed a discrepancy, with more nicotine patches remaining in the medication sleeve than should have been present according to the eMAR and administration history. Interviews with the QMA and the Director of Nursing (DON) confirmed that the patch was not administered as ordered and was documented as given before actual administration. The facility's policy requires documentation to occur after medication administration, but this procedure was not followed, resulting in inaccurate medication records and unaccounted patches.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure a self-administration assessment was completed for a resident who was observed self-administering her medications without supervision. During a breakfast meal observation, a resident was seen taking four pills from a medication cup on her table without any staff present. The resident's medical record indicated diagnoses of essential hypertension, heart failure, and age-related macular degeneration, and she was on medications including a diuretic and an antiplatelet. However, there was no documentation in her records of an assessment to determine her ability to self-administer medications, nor was there a physician's order permitting her to do so. Interviews with the resident and staff revealed inconsistencies in medication administration practices. The resident mentioned that some nurses left her medications on the table for her to take later, while others did not comply with her request. The Director of Nursing and Licensed Practical Nurses confirmed that residents should not be left to self-administer medications unsupervised. The facility's policy required an interdisciplinary team assessment and a physician's order for self-administration, which was not followed in this case.
Deficiency in Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure timely completion of care plan meetings for two residents, leading to deficiencies in care planning documentation. Resident 12, who was cognitively intact with a BIMS score of 14, reported not having a care plan meeting in the last three years. Upon review, documentation was missing for a period between September 2023 and February 2024. The Social Services Director (SSD) admitted to not completing meeting notes and failing to use the electronic medical record system properly, resulting in a lack of evidence that care plan meetings occurred. Similarly, Resident 24, who had moderate cognitive impairment, could not recall attending recent care plan meetings. The resident's records showed a gap in documentation of quarterly care plan meetings between August 2023 and April 2024. The SSD acknowledged the oversight in documentation and the facility's policy required quarterly and annual care plan meetings. The Administrator confirmed the absence of documentation for quarterly meetings, highlighting a systemic issue in adhering to the facility's care planning policy.
Improper Wound Care by QMA
Penalty
Summary
The facility failed to ensure that a Qualified Medication Aide (QMA) adhered to proper standards of practice in the care of a resident with pressure ulcers. Resident 218, who had several pressure ulcers upon admission, reported that QMA 3 had previously completed dressing changes for her pressure ulcers. However, the facility's policy restricts QMAs from performing dressing changes on advanced skin conditions, including Stage II, III, and IV pressure ulcers. During the review, it was found that QMA 3 documented completing dressing changes for Resident 218's pressure wounds on four out of nine days, despite the facility's policy that only licensed nursing staff should perform such tasks. The Director of Nursing (DON) confirmed that QMAs are only permitted to perform dressing changes on Stage I wounds or less. The QMA claimed that her initials appeared in the documentation due to accidentally selecting the wrong option while administering medications. Observations revealed that the dressings on Resident 218's wounds were not properly dated or initialed by staff, as required by the facility's policy. The Assistant Director of Nursing (ADON) confirmed that staff should date and initial dressings when completed. This oversight in documentation and adherence to policy contributed to the deficiency in the care provided to Resident 218.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling practices, as observed during a survey. In one instance, a personal drink belonging to an LPN was found stored in the bottom drawer of a medication cart among residents' medications. The LPN acknowledged that food or drink should not be stored inside medication carts, and the facility's administrator confirmed that staff were not supposed to have personal drinks in patient care areas, including medication carts. Additionally, the facility did not dispose of expired medication for a resident. Latanoprost 0.005% eyedrops, which were only good for six weeks after opening, were found in the medication cart with an opened date exceeding the recommended usage period. The LPN was aware of the expiration and had ordered a replacement, but the new medication was not delivered in time. The resident's medical records indicated that the expired medication was administered on several occasions, and the LPN confirmed that the medication should have been documented as expired until the new bottle arrived. The facility's policy on medication storage and expiration was not adhered to, as expired medications were not stored separately until destruction or return to the pharmacy.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vermillion Convalescent Center | 1.2 mi | ★★★★★ | 11 | 0 |
| Majestic Care Of Terre Haute | 10.5 mi | ★★★★★ | 9 | 0 |
| Providence Health Care Center | 10.6 mi | ★★★★★ | 1 | 0 |
| Signature Healthcare Of Terre Haute | 11.6 mi | ★★★★★ | 19 | 0 |
| Harrison's Crossing Health Campus | 11.9 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.