Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Clark-lindsey Village during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments was left without timely incontinence care and repositioning by staff, resulting in significant pain and distress. During a transfer, two CNAs improperly positioned the resident, ignored requests for assistance, and forced the resident to have a bowel movement in a garbage can. Staff then left the resident soiled and in pain, while family and private caregivers were compelled to provide essential care due to ongoing staff neglect. Facility leadership failed to act on repeated complaints or follow abuse prevention policies.
A resident who was cognitively impaired and fully dependent on staff for care received medications from an unlicensed private caregiver and the resident's POA, rather than from licensed nurses. Nursing staff routinely provided medications to these untrained individuals for administration, citing lack of time to wait for the resident to take her medications. Facility policy required licensed nurses to administer medications and remain with the resident, but this was not followed, and medications and supplies were left in the resident's room for unlicensed administration.
Nursing staff failed to accurately document medication administration for a resident who was fully dependent on staff, instead providing medications to the resident's POA and private caregivers and signing the MAR as if they had administered the medications themselves. This practice was inconsistent with facility policy and resulted in inaccurate medical records.
A resident who was cognitively intact and required assistance with daily activities was not allowed to eat breakfast in the dining room as she preferred, due to staffing shortages. Her care plan did not address her right to make choices, and staff confirmed that multiple residents were unable to go to the dining room for meals because of insufficient staff. The interim DON acknowledged the issue, noting that resident care requests should be honored.
A resident who was cognitively impaired and fully dependent on staff experienced pain and distress during a transfer, leading to a grievance raised by the resident's POA regarding care quality and staff behavior. Despite multiple communications, the facility did not document, follow up, or resolve the grievance, and the designated Grievance Officer was not informed, contrary to facility policy.
A resident who was cognitively impaired and fully dependent on staff was left in pain and distress during a transfer, forced to have a bowel movement in a garbage can, and not provided with necessary incontinence care or repositioning. The resident's POA and private caregivers reported ongoing neglect and were required to provide most care themselves. Despite being informed of the incident and ongoing concerns, facility leadership did not report the allegation of neglect to the State Surveying Agency as required by policy.
A resident who was cognitively impaired and fully dependent on staff was left in pain and without proper incontinence care after an incident involving improper use of a mechanical lift. The resident's POA and private caregivers reported ongoing neglect and lack of staff response, but the facility did not investigate or report the allegation as required by policy.
A resident admitted after a craniectomy did not receive physician-ordered daily skin checks, antiseptic shampoo, or required helmet use, and Enhanced Barrier Precautions were not implemented. Staff failed to monitor or document the surgical site, did not use appropriate PPE, and used standard soap instead of the ordered antiseptic. These failures led to a surgical site infection requiring antibiotics, hospitalization, and surgical debridement.
A resident with significant medical needs reported to their spouse that their head was bumped during a transfer for a shower, and the spouse informed an LPN. Although the LPN and DON checked for injury and found none, no immediate investigation or follow-up was conducted, and the incident was not documented or addressed according to the facility's grievance policy until a month later.
A resident with significant neurological and mobility impairments reported her head was bumped during a shower transfer, causing pain at a previous incision site. Although the incident was reported to an LPN by the resident's husband, no investigation or care plan update was initiated until more than a month later. Staff involved were not questioned about the event until much later, and the facility did not follow its policy for prompt incident reporting and investigation.
A resident with poor core strength fell from a reclining wheelchair that was not fully reclined, resulting in a head injury and hematoma. The facility also failed to maintain safe equipment, as sharp bolts under the wheelchair armrests caused skin tears. Additionally, the resident was improperly transferred using a sit-to-stand lift instead of a full mechanical lift, as required.
The facility failed to ensure dietary staff followed the hair restraint policy, risking food contamination. A cook was observed with a stocking cap that inadequately covered their hair, and the Dining Services Supervisor was seen without a beard net. These actions could affect all 20 residents.
A resident sustained skin tears from sharp bolts on a wheelchair, which was not promptly identified or repaired by the facility. The DON and Maintenance Director were initially unaware of the wheelchair's location, and it was later found in the physical therapy office, potentially still in use by other residents.
The facility failed to promptly notify a resident's Power of Attorney about skin tears and did not inform a physician about another resident's significant weight gain. The first resident's injury was reported to the Power of Attorney hours after it occurred, and the second resident's weight gain was documented but not communicated to the physician.
The facility did not follow its abuse prevention policy when a resident's Power of Attorney reported concerns of potential abuse to the DON. The Administrator failed to notify the state agency or investigate the allegation. Furthermore, the DON had not received the required abuse training, as indicated by the facility's records.
A facility failed to report an abuse allegation to the State Agency. A resident's Power of Attorney reported concerns to the DON about the resident saying 'Don't hurt me' during care. The Administrator received this allegation but did not notify the state agency, and the resident's medical record lacked documentation of such notification.
A facility failed to investigate an abuse allegation involving a resident who expressed distress during care. The resident's Power of Attorney reported the concern to the DON, who then informed the Administrator. Despite this, the Administrator did not conduct an investigation, and the resident's medical record showed no documentation of any follow-up.
A facility failed to update a resident's care plan to reflect a change from a mechanically altered diet to a pureed diet with nectar thickened liquids, as ordered by a physician. The oversight was discovered when the resident's water pitcher contained regular water, contrary to the prescribed diet. The Care Plan Coordinator acknowledged the failure to update the care plan.
A facility failed to develop a care plan for a resident on Hydrocodone-Acetaminophen, neglecting to address constipation, a known side effect. Despite receiving the medication twice daily, the resident had no bowel movement for six days, and no interventions were initiated, contrary to the facility's bowel protocol. Staff confirmed the lack of bowel movements and interventions.
A facility failed to follow proper hand hygiene and glove-changing protocols during incontinence care for a resident with a history of UTIs. Two CNAs assisted the resident to the toilet, but one CNA did not change gloves or sanitize hands after cleansing the perineal area and before applying a new incontinence brief, acknowledging the oversight.
A facility failed to document behaviors and implement non-pharmacological interventions before increasing an antidepressant dosage for a resident with Dementia, Anxiety, and Insomnia. The facility's policy requires such documentation and attempts at Gradual Dose Reductions (GDR) unless contraindicated. However, there was no documentation of behaviors or non-pharmacological interventions prior to increasing Remeron, nor was there an attempt or declination of a GDR for Sertraline within the last year.
The facility failed to properly store medications, including schedule II controlled substances, as per policy. An LPN found an unlocked refrigerator containing Lorazepam and expired medications in the storage area. Additionally, a resident had an Albuterol inhaler stored improperly on a bookcase. The DON confirmed these storage issues, which violated the facility's medication storage policy.
A resident with dysphagia was not provided with the prescribed pureed diet and thickened liquids, as the facility gave regular water with a straw and non-pureed food. The DON and an Advanced Nurse Practitioner confirmed the facility's failure to adhere to the dietary orders, leading to a deficiency in care.
Two CNAs failed to follow proper hand hygiene protocols, leading to potential cross-contamination. One CNA did not change gloves or sanitize hands after providing incontinence care to a resident, while another handled soiled items and assisted residents without performing hand hygiene. These actions violated the facility's infection control policy.
Failure to Protect Resident from Abuse and Neglect by Staff
Penalty
Summary
A resident with multiple complex medical conditions, including Alzheimer's disease, dementia, protein-calorie malnutrition, and significant physical impairments, was not provided with timely and appropriate care by facility staff. The resident was completely dependent on staff for all activities of daily living, including repositioning, incontinence care, feeding, and medication administration. According to the care plan, staff were instructed to anticipate and meet the resident's needs, including frequent position changes and incontinence care at least every two hours. However, interviews and review of camera footage revealed that staff often failed to enter the resident's room for extended periods, sometimes up to six or eight hours, leaving the resident without necessary care. On a specific occasion, two CNAs transferred the resident using a mechanical lift and toilet sling. During the transfer, the resident was improperly positioned, resulting in significant pain and distress, as evidenced by the resident's crying, screaming, and yelling. The resident continued to have a bowel movement during the transfer, and instead of repositioning the resident or returning her to the toilet as requested by her power of attorney, the staff placed a garbage can under her, forcing her to have a bowel movement in it. The staff then left the resident on her bed without completing incontinence care or ensuring she was safely positioned, leaving her soiled and in pain. The resident's family and private caregivers reported that they were frequently required to provide all aspects of care, including repositioning, feeding, and medication administration, due to staff neglect. Facility leadership was made aware of these concerns, but failed to take appropriate action. The interim DON acknowledged receiving multiple complaints from the resident's power of attorney and confirmed that staff should be providing care every two hours. Despite requests to prevent the involved CNAs from caring for the resident, they continued to do so. The administrator in training admitted that the facility did not follow its abuse policy and did not properly report or investigate the incident. The facility's own policy states that residents must be free from abuse and neglect, and that staff must intervene to prevent such occurrences, but these standards were not upheld in this case.
Unlicensed Individuals Administered Medications Without Nurse Supervision
Penalty
Summary
Licensed nurses at the facility failed to administer medications as required, instead allowing an unlicensed private caregiver and the resident's Power of Attorney (POA) to administer medications on multiple occasions. The resident in question was documented as moderately cognitively impaired and completely dependent on staff for all activities of daily living, including eating, oral hygiene, toileting, showering, dressing, bed mobility, and transfers. The resident had multiple physician orders for daily and scheduled medications, including antibiotics, supplements, and medications for chronic conditions. Despite these needs, observations and interviews revealed that the private caregiver, who was not a licensed nurse and had no formal training in medication administration, was routinely given the resident's medications by nursing staff to administer without supervision. The private caregiver reported that nurses told her and other caregivers they did not have time to wait for the resident to take her medications, as she was a slow swallower. The caregiver described daily practices of mixing and administering medications, including thickening liquids and crushing pills, without knowledge of proper dosages, side effects, or potential interactions. The nurse confirmed that she prepared the medications and provided them to the POA or private caregivers for administration, stating that this was a common practice among staff and approved by facility administration. The Interim Director of Nursing (DON) also acknowledged giving approval for the POA and private caregivers to administer medications without a nurse present, despite their lack of licensure or training. Facility policy required that licensed nurses administer medications, remain with the resident until the medication is swallowed, and not leave medications in the resident's room without orders. The policy also specified that medications must be administered by legally authorized and trained persons in accordance with applicable laws and standards of practice. However, observations showed that medications, thickener, and pill crushers were left in the resident's room, and the private caregivers continued to administer medications daily, contrary to facility policy and regulatory requirements.
Inaccurate Medication Administration Records Due to Improper Delegation
Penalty
Summary
Facility staff failed to maintain accurate medical records and safeguard resident-identifiable information for one resident who was moderately cognitively impaired and completely dependent on staff for all activities of daily living, including medication administration. The resident's physician orders included multiple daily and twice-daily medications for various conditions, such as recurrent urinary tract infections, vaginal candidiasis, and chronic health issues. Despite these orders, nursing staff, including an RN and an LPN, reported that they routinely provided the resident's medications to the resident's Power of Attorney and private caregivers, rather than administering the medications themselves. Both staff members admitted to signing the Medication Administration Record (MAR) as if they had administered the medications, even though they could not confirm the medications were actually given to the resident. The facility's policy required that nurses document medication administration in the MAR immediately after personally administering the medication to each resident. The policy also specified that medications must be administered by legally authorized and trained persons in accordance with applicable laws and accepted standards of practice. The interim Director of Nursing confirmed that staff are expected to document only the work they perform and to ensure that medications are administered before signing the MAR. The actions of the nursing staff, as described in interviews and record reviews, were inconsistent with both facility policy and professional standards, resulting in inaccurate medical records for the resident.
Failure to Honor Resident's Right to Make Choices Due to Staffing Issues
Penalty
Summary
A cognitively intact resident who requires assistance with eating, oral hygiene, dressing, bed mobility, and transfers was not provided with the opportunity to exercise her right to make choices about her daily routine. The resident's care plan did not include any focus area, goal, or interventions related to her right to make her own choices. On the morning in question, the resident expressed a preference to get up earlier and eat breakfast in the dining room to socialize with other residents, but was instead served breakfast in bed due to reported staffing shortages. The resident stated that while she understood the staff were working hard, it had become the norm for her to eat breakfast in bed because of low staffing, which was not her preference. Staff interviews confirmed that there were not enough staff available that morning to assist all residents who wished to go to the dining room for breakfast. A CNA acknowledged that several residents who would normally eat in the dining room could not do so due to lack of staff, and that residents should be able to go to the dining room if they choose. The interim DON stated that the facility met regulatory staffing requirements but recognized that resident care requests should be honored and was aware of the staffing concerns on the resident's hall. The facility's failure to honor the resident's right to make choices about her daily routine, specifically regarding meal location and timing, was directly linked to staffing issues and lack of care plan interventions.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to document, follow up, and resolve a grievance for one resident who was moderately cognitively impaired and required maximum assistance for all activities of daily living. The resident's Power of Attorney (POA) reported an incident where the resident, while being transferred using a mechanical lift, was not positioned correctly, resulting in the resident screaming in pain and being forced to have a bowel movement in a garbage can. The POA communicated these concerns multiple times, including via email, and specifically requested that the involved CNAs not provide further care to the resident. Despite these requests, the same CNAs continued to care for the resident, and the POA was told by the Interim DON that no further action could be taken and that the CNAs were not the resident's primary caregivers. The facility did not maintain a grievance log or reports for the past three months, and the Interim DON did not report the POA's concerns to the designated Grievance Officer, believing the concerns did not warrant being classified as a grievance. The Administrator in Training was informed of the situation but was told by the Interim DON that it was being handled and did not need to be elevated to a grievance report. The Grievance Officer later confirmed that the concerns should have been reported as a grievance, as per facility policy, which allows grievances to be raised by residents, representatives, staff, or visitors and does not require a formal written complaint.
Failure to Report Alleged Neglect and Inadequate Resident Care
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident who was moderately cognitively impaired and completely dependent on staff for all activities of daily living, including personal hygiene, eating, toileting, and mobility. The resident's Power of Attorney (POA) reported that the resident often waited 30-60 minutes for staff to respond to call lights and that personal cameras in the resident's room showed staff not entering for multiple hours. On the date of the incident, two CNAs used a mechanical lift with a toilet sling to transfer the resident, during which the resident was improperly positioned, experienced pain, and was left exposed and distressed. The POA witnessed the resident being forced to have a bowel movement in a garbage can while screaming in pain, and the CNAs refused to reposition the resident or provide further care, leaving the resident soiled and uncomfortably positioned in bed. The POA and private caregivers reported that they were required to provide most of the resident's care, including repositioning, feeding, administering medications, and hygiene, due to staff neglect. The POA communicated these concerns, including the specific incident, to the Interim DON via email and requested that the involved CNAs not provide further care to the resident. Despite these communications, the CNAs continued to care for the resident, and the DON responded that they were not the resident's primary CNAs, so it was acceptable. The POA was told by the DON that no one else could address the ongoing care concerns. The Administrator in Training (AIT) acknowledged being made aware of the family's concerns but stated that the Interim DON was handling the situation and did not escalate the issue or report it as a grievance. The facility did not report the allegation of neglect to the State Surveying Agency as required by their abuse prevention policy, which mandates immediate reporting of abuse or neglect allegations. Both the AIT and Interim DON confirmed that the incident was not reported, and the facility did not follow its own abuse policy.
Failure to Investigate and Report Allegation of Resident Neglect
Penalty
Summary
The facility failed to investigate an allegation of neglect involving a resident who was moderately cognitively impaired and completely dependent on staff for all activities of daily living, including personal hygiene, eating, toileting, and mobility. The resident's Power of Attorney (POA) reported that the resident was left waiting for extended periods for staff assistance, and that on one occasion, the resident was improperly positioned in a mechanical lift, causing pain and distress. During this incident, the resident was forced to have a bowel movement in a garbage can while in pain and was left without proper incontinence care or safe repositioning in bed. The POA and private caregivers reported that they frequently had to provide all care, including medication administration, due to staff neglect and lack of timely response to call lights. Despite the POA's immediate report of the incident to the Interim Director of Nursing (DON) via email, there was no documented investigation into the allegation of neglect. The POA and private caregivers were not interviewed for witness statements, and the staff members involved continued to provide care to the resident after the incident. The Interim DON acknowledged receiving the complaint and stated that the staff involved reported the incident a week later, but no formal investigation was initiated, and the allegation was not reported to the State Agency as required by facility policy. The Administrator in Training (AIT) was informed of the family's concerns but deferred to the Interim DON, who indicated she was handling the situation. The facility's abuse prevention policy requires immediate investigation and notification of the Administrator for any suspected incident, but these steps were not followed. The failure to investigate and report the allegation of neglect constitutes a deficiency in the facility's response to alleged violations.
Failure to Follow Physician Orders and Infection Control for Surgical Site
Penalty
Summary
The facility failed to follow physician admission orders and provide appropriate care for a resident who was admitted after a cerebral vascular accident and craniectomy. The resident had specific physician orders for daily skin checks, use of antiseptic/disinfectant shampoo on the surgical site, wearing a cranium helmet when out of bed, and craniectomy precautions. Upon review, there was no documentation that these orders were implemented. The resident's admission assessment did not note the surgical site, helmet use, or required isolation precautions. The Medication Administration Record and Treatment Administration Record did not include the necessary orders for daily skin checks, helmet use, or antiseptic shampoo. Staff interviews confirmed that the resident was not receiving the ordered care, and the surgical site was not being monitored or cleaned as directed. Observations revealed that the resident's room lacked signage for Enhanced Barrier Precautions (EBP), and there was no accessible personal protective equipment (PPE) or designated disposal bins. Staff, including LPNs and CNAs, were observed providing care and handling the resident's helmet and surgical site without wearing appropriate PPE or following EBP protocols. The resident's helmet, which had openings exposing the scalp, was handled with bare hands, and the surgical site was left uncovered and draining. Staff were unaware of the need for antiseptic shampoo and used standard facility soap instead. There was no communication or documentation of changes in the surgical site, and staff did not report redness or drainage to nursing or medical staff. Family members and medical professionals expressed concerns that the lack of adherence to physician orders and failure to monitor and care for the surgical site led to the development of a Methicillin Susceptible Staphylococcus Aureus (MSSA) infection. This infection required additional medical interventions, including antibiotics, a second hospitalization, and surgical debridement of the scalp. Facility leadership acknowledged that the required orders were not implemented, the surgical site was not assessed or monitored, and EBP was not initiated upon admission. The facility also lacked a wound care program for non-pressure-related wounds, contributing to the failure to provide appropriate care for the resident's surgical site.
Failure to Promptly Investigate and Resolve Resident Grievance
Penalty
Summary
The facility failed to follow its Grievance Policy by not promptly investigating and resolving a complaint made by a resident regarding an incident during a transfer. The resident, who had significant medical conditions including cerebral infarction, hemiplegia, and dysphagia, was dependent on staff for most activities of daily living. The incident involved the resident's head being bumped during a transfer for a shower, which was reported by the resident's spouse to an LPN. Both the LPN and the DON examined the resident and found no injury, but no further investigation or documentation was completed at that time. The facility's grievance log later documented the complaint, but the investigation and assessment were not initiated until a month after the incident. The Grievance Officer confirmed that the facility did not follow its policy, which requires prompt investigation, communication with the resident, and thorough documentation. There was no evidence of interviews with the resident, staff, or witnesses, nor was there a root cause analysis conducted immediately following the complaint. The lack of timely follow-up and investigation resulted in the facility not meeting its own grievance resolution standards.
Failure to Timely Investigate and Update Care Plan After Resident Accident
Penalty
Summary
The facility failed to timely investigate an accident and update the care plan for a resident who reported her head was bumped during a shower transfer. The resident, who had a history of cerebral infarction, hemiplegia, dysphagia, lack of coordination, and required extensive assistance with activities of daily living, stated that after being assisted into a shower chair by two CNAs, one left the room and the other continued with the shower. The resident reported that her head was bumped when the staff pushed her shower chair too quickly around a bathroom corner, causing significant pain at the site of a previous incision. The incident was reported by the resident's husband to an LPN on the same day, but no investigation or care plan update was documented in the electronic medical record at that time. Interviews with the resident, her husband, and multiple staff members revealed that no one was questioned about the incident until over a month later. The DON confirmed that although the incident was reported, no investigation was initiated because there was no visible injury. The facility's policy required that incident reports be completed promptly and investigations started within 24 hours, with findings and interventions documented and shared with relevant staff. This process was not followed, resulting in a lack of timely investigation and care plan revision after the reported accident.
Failure in Wheelchair Positioning and Equipment Safety Leads to Resident Injury
Penalty
Summary
The facility failed to ensure proper wheelchair positioning and safe equipment use, resulting in a fall and injury for a resident. The resident, who had poor core strength and was undergoing therapy, was found on the floor after falling from a reclining wheelchair that was not fully reclined. This led to a head injury and a hematoma on the left forehead. The Director of Nursing's investigation revealed that the resident's fall was due to the wheelchair not being reclined, which was necessary given the resident's poor core strength. Additionally, the facility failed to maintain safe equipment, as the resident sustained skin tears from sharp bolts under the wheelchair armrests. The Maintenance Director admitted there was no process to ensure wheelchairs were safe before use. Furthermore, the resident, who was designated for a full mechanical lift transfer, was improperly transferred using a sit-to-stand lift by CNAs, contrary to the transfer directive. These failures in supervision and equipment safety contributed to the resident's injuries.
Failure to Adhere to Hair Restraint Policy in Dining Services
Penalty
Summary
The facility failed to ensure that dietary staff adhered to the Dining Services Hair Restraint Policy, which mandates that all staff involved in food preparation, service, and handling must wear appropriate hair restraints at all times. During an observation, a cook was seen wearing a stocking cap that inadequately covered their hair, allowing three inches of gray curly hair to hang loosely beneath the cap. Additionally, the Dining Services Supervisor was observed in the food preparation area without a beard net, leaving their gray facial hair uncovered. These lapses in following the hair restraint policy have the potential to lead to physical contamination of food, food-contact surfaces, and equipment, affecting all 20 residents residing in the facility.
Unsafe Wheelchair Condition Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a wheelchair was in safe operating condition for one resident, which had the potential to affect all 20 residents in the facility. An incident report documented that a resident sustained skin tears on both forearms due to metal bolts with rough edges on the underside of the wheelchair arms. The Assistant Director of Nursing and the Director of Nursing confirmed the presence of sharp bolts on the wheelchair. However, the Director of Nursing was initially unaware of the wheelchair's location. The Maintenance Director stated there was no work order for the wheelchair, and he was also unsure of its location. Later, the Director of Nursing mentioned that they might have found the wheelchair in the physical therapy office, but it was uncertain if it was the same wheelchair that caused the injuries, indicating it could still be in use by other residents.
Failure to Notify Power of Attorney and Physician
Penalty
Summary
The facility failed to immediately notify the Power of Attorney of an injury and did not inform the physician of a significant weight gain for two residents. In the first case, a resident was found with skin tears on both arms at 11:00 AM, but the Power of Attorney was not notified until 5:12 PM. The Director of Nursing confirmed the delay in notification. In the second case, a resident experienced a weight gain of 20.4 pounds over several months, but the physician was not informed of this change. The resident's weight logs and nutrition assessment documented the weight gain, yet there was no record of physician notification. The facility administrator confirmed the oversight in notifying the physician about the weight gain.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its abuse prevention and prohibition policy for a resident who was reviewed for abuse. The policy, dated 1/30/23, requires immediate notification to the state agency and an investigation upon receiving an allegation of abuse. However, when the Power of Attorney for the resident reported concerns about potential abuse to the Director of Nursing, the Administrator did not notify the state agency or investigate the allegation. Additionally, the Director of Nursing, who had been working at the facility for a month, had not received the required abuse training, as confirmed by the facility's training records.
Failure to Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency for one resident reviewed for abuse. On February 3, 2025, the Power of Attorney for the resident expressed concern that the resident had been saying, 'Don't hurt me' during care, which was reported to the Director of Nursing. The Administrator acknowledged receiving this allegation on February 1, 2025, but did not notify the state agency. The resident's medical record lacked documentation that the state agency was informed of the abuse allegation.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident. On February 3, 2025, the resident's Power of Attorney expressed concern to the Director of Nursing that the resident had been saying, 'Don't hurt me' during care, suggesting possible abuse. This concern was reported to the Administrator on February 1, 2025. However, the Administrator admitted to not investigating the allegation. The resident's medical record lacked documentation of any investigation following the report of the alleged abuse.
Failure to Revise Resident's Care Plan for Diet Change
Penalty
Summary
The facility failed to revise the care plan for a resident who was on a pureed texture diet with nectar thickened liquids as per a physician's order dated January 24, 2025. On February 3, 2025, it was observed that the resident's water pitcher contained regular water, which was not in accordance with the prescribed diet. The resident's care plan, last revised on January 23, 2025, inaccurately documented that the resident was receiving a mechanically altered texture diet instead of the updated pureed diet. The Care Plan Coordinator admitted on February 6, 2025, that she did not update the care plan to reflect the change in diet when the order was changed.
Failure to Address Opioid-Induced Constipation
Penalty
Summary
The facility failed to develop a care plan addressing potential adverse reactions to opioid medications for a resident with a recent hip fracture, who was receiving Hydrocodone-Acetaminophen. The care plan did not include measures to monitor or prevent constipation, a known side effect of prolonged opioid use. The resident's Medication Administration Record indicated they received the medication twice daily, yet their Bowel and Bladder tracking record showed no bowel movement for six days. Despite the facility having a bowel protocol to address such issues, no interventions were initiated for the resident. Interviews with a Licensed Practical Nurse and a Certified Nursing Assistant confirmed the lack of bowel movements and the absence of any interventions to treat or prevent constipation.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene and glove-changing protocols during incontinence care, which is critical for preventing urinary tract infections. A resident with a history of urinary tract infections was assisted to the toilet by two Certified Nursing Assistants (CNAs). After securing the resident in a mechanical lift and moving them to the bathroom, the CNAs removed their gloves, used hand sanitizer, and applied new gloves. However, one CNA did not change gloves or sanitize hands after cleansing the resident's perineal area and before applying a new incontinence brief. This lapse in infection control practices was acknowledged by the CNA involved, who admitted to not changing gloves before applying the new brief.
Failure to Document Behaviors and Implement Non-Pharmacological Interventions Before Antidepressant Increase
Penalty
Summary
The facility failed to document behaviors and implement non-pharmacological interventions before increasing the dosage of an antidepressant for a resident diagnosed with Dementia, Anxiety, and Insomnia. The facility's policy requires that psychotropic medications be used only after documented behavioral programming with non-pharmacological interventions has been attempted and proven unsuccessful. Additionally, Gradual Dose Reductions (GDR) should be attempted annually unless clinically contraindicated. However, for the resident in question, there was no documentation of behaviors or unsuccessful non-pharmacological interventions prior to the increase in the antidepressant Remeron from 15 mg to 30 mg. Furthermore, there was no attempt or documented declination of a GDR for another antidepressant, Sertraline, within the last year. The resident's medical records, including the Minimum Data Set and Medication Administration Records (MARs), did not document any behaviors or non-pharmacological interventions during the months leading up to the medication increase. The facility's administrators confirmed the lack of documentation for behaviors and non-pharmacological interventions, as well as the absence of a GDR attempt for Sertraline. The increase in Remeron was reportedly due to the resident's poor appetite and crying, as requested by the resident's family, but these behaviors were not documented in the nursing notes as required by the facility's policy.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage policy, resulting in several deficiencies. During an observation, it was found that the medication storage room's refrigerator was unlocked and contained two bottles of liquid Lorazepam, a schedule II controlled substance, which were not stored behind double locks as required. Additionally, expired medications, including bisacodyl suppositories and acetaminophen suppositories, were found in the medication storage area. The Licensed Practical Nurse (LPN) on duty confirmed the expiration of these medications and removed them upon discovery, acknowledging that they were unaware of their expired status. The Director of Nursing (DON) verified that the expired medications should have been disposed of and that the medication refrigerator should have been locked. Another deficiency was observed when an Albuterol Sulfate inhaler was found on a bookcase next to a resident's bed. The resident stated that the inhaler was no longer in use and was simply stored there. This was in violation of the facility's medication storage policy, which mandates that medications be kept secure in the medication room or medication cart. The facility's daily census documented 20 residents in the certified unit at the time of the survey.
Failure to Follow Prescribed Diet for Resident with Dysphagia
Penalty
Summary
The facility failed to provide food and liquids in the correct form for a resident with dysphagia, as documented in the hospital discharge records. The resident, who had a stroke, was ordered a pureed diet with nectar thickened liquids and was not to use a straw. However, observations and interviews revealed that the facility did not adhere to these dietary requirements. The resident's Power of Attorney reported that the facility provided regular water with a straw and non-pureed food, such as regular green beans, contrary to the prescribed diet. Further investigation confirmed these discrepancies. The Director of Nursing acknowledged concerns that the resident's diet was not being followed, and the Advanced Nurse Practitioner confirmed that the facility was not adhering to the hospital's diet orders. Observations showed that the resident's water pitcher contained regular water, and a Certified Nursing Assistant confirmed it was not thickened. These actions and inactions led to the deficiency in providing appropriate dietary care for the resident with dysphagia.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The deficiency involves a failure in infection prevention and control practices by staff members at the facility. Specifically, two Certified Nursing Assistants (CNAs), identified as V19 and V20, did not adhere to the facility's hand hygiene policy during the provision of care to residents. On one occasion, V20 failed to remove gloves and perform hand hygiene after providing incontinence care to a resident, R15. Instead, V20 continued to handle various items, including a mechanical lift, remote, linens, and clothing, without changing gloves or sanitizing hands, which could lead to potential cross-contamination. In another instance, V20 was observed carrying a bag of soiled briefs without gloves on one hand and failed to perform hand hygiene after disposing of the bag. V20 then proceeded to calibrate a scale and assist another resident, R8, without changing gloves or sanitizing hands. Additionally, V20 was seen touching his nose, adjusting his mask and glasses, and using a tablet without removing soiled gloves or performing hand hygiene. These actions demonstrate a lack of compliance with the facility's infection control protocols, potentially compromising resident safety.
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Illustrative
What surveyors actually found near you
We read the 95 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Urbana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accolade Healthcare Of Savoy | 2.5 mi | ★★★★★ | 23 | 0 |
| Haven Of Champaign | 4.3 mi | ★★★★★ | 14 | 0 |
| Country Health | 18.4 mi | ★★★★★ | 23 | 0 |
| Piatt County Nursing Home | 19.4 mi | ★★★★★ | 0 | 0 |
| The Haven Of Tuscola | 21.1 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.