Clark-Lindsey Village: Medication Safety Failures - IL
The arrangement had been running for months by the time state inspectors arrived in October.
The resident, identified in inspection records only as R7, requires medications that are crushed and mixed with thickened liquids. R7 takes forever to swallow, according to a licensed practical nurse who told inspectors on October 15 that she simply didn't have time to wait. "I would still be in there if I had to do that," the nurse said. "I don't have time for that."
So the facility found another solution. A coordinator ordered R7's thickener and pill crusher kept in R7's room so that the private caregivers and R7's power of attorney could handle it themselves without flagging down nurses. R7's power of attorney told inspectors the coordinator made that call because the family was "bothering" the nurses too much by asking for pills to be crushed and drinks to be thickened.
On July 22, the interim director of nurses emailed R7's power of attorney directly, stating the family could administer R7's medications without a nurse present. That email went out three months before inspectors walked in.
V17, one of R7's private caregivers, told inspectors she had been giving R7's medications every day and had done so for months. She said the facility's management gave the family and caregivers approval to do it. She also told inspectors she is not a licensed nurse and has never had any formal training in medication administration. Nobody at the facility, inspectors noted, had verified whether any of R7's private caregivers had any medical knowledge at all.
On the afternoon of October 14, inspectors found R7's Benefiber and Miralax sitting in cups on the bedside table, untaken. The gallon jug of thickener, packets of thickener, and a pill crusher were arranged on the dresser. V17 told inspectors the Benefiber had gone "stone thick" from sitting out too long.
The next morning, inspectors returned to find one of R7's other private caregivers feeding R7 breakfast, including what she described as R7's potassium liquid mixed with vanilla ice cream and thickener. The caregiver said the nurses now had to mix all of R7's medications, a change apparently made after inspectors arrived. She also said the cups on the table still held R7's Miralax and Benefiber from the previous day. "We are working on getting all the medications down," she told inspectors. "The staff say they don't have time to stay with R7."
The licensed practical nurse who spoke with inspectors that same morning confirmed she had given R7's medications earlier, but not the Miralax, Benefiber, or potassium. Those she left.
By late afternoon on October 15, the interim director of nurses told inspectors that licensed nurses should be administering all medications. She confirmed she had given the power of attorney approval to administer R7's medications. She said the facility would need to review its medication administration policy and educate staff.
The facility's own policy, dated June 17, 2025, states that a licensed nurse must identify the resident before giving medications, remain with the resident until the medication is swallowed, and not leave medications in a resident's room without a specific order to do so. It also states medications must be given by legally authorized and trained persons.
The interim director of nurses approved an arrangement that violated every one of those requirements. She did it by email. She did it in July. And for months, an untrained caregiver crushed pills and thickened drinks and administered medications to a resident who, according to the facility's own nurses, takes a long time to swallow — while the nurses moved on to other rooms.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clark-lindsey Village from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 25, 2026 · Our methodology
CLARK-LINDSEY VILLAGE in URBANA, IL was cited for violations during a health inspection on October 15, 2025.
The arrangement had been running for months by the time state inspectors arrived in October.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.