Clark Rehab: Nurse Falsified Narcotic Records - IN
The inspection, completed October 29, 2025, was triggered by a complaint. What investigators found at the 517 N. Little League Boulevard facility was a pattern that played out across at least two residents and two consecutive nights: a licensed practical nurse, identified in records as LPN 10, signing out hydrocodone that the cameras and the residents themselves said was never given.
Resident D had a physician's order, in place since July 30, 2025, for Hydrocodone-Acetaminophen 5-325 mg every six hours, scheduled at noon, 6:00 p.m., midnight, and 6:00 a.m., for chronic pain. The resident's diagnoses included Parkinson's disease, chronic pain, depression, and peripheral vascular disease. The October 2025 controlled substance record showed LPN 10 had signed out the narcotic as administered on October 7 at 10:00 p.m., October 8 at 2:00 a.m., October 8 at 10:00 p.m., and October 9 at 2:00 a.m.
The camera told a different story.
On the night of October 7, video footage showed LPN 10 entering Resident D's room at 9:13 p.m. carrying a medication cup. She left four minutes later, at 9:17 p.m. From that moment until 3:30 a.m. on October 8, she did not go back in. The controlled substance record said she had administered medication at 10:00 p.m. and again at 2:00 a.m.
The following night followed the same pattern. LPN 10 entered Resident D's room at 9:38 p.m. on October 8 with a medication cup and water. She was out in under a minute. From 9:38 p.m. until 3:30 a.m. on October 9, she did not return. Her signature on the narcotic record said she had given the medication at 10:00 p.m. and 2:00 a.m.
The Regional Nurse Consultant confirmed what the footage showed. In an interview on October 29 at 1:48 p.m., the consultant said that based on the video reviewed for the period between October 7 and October 9, from 11:00 p.m. to 3:30 a.m., LPN 10 did not enter Resident D's room to administer any medications.
The Executive Director provided investigators with a timeline on October 29 at 2:26 p.m. that laid out the camera findings in detail, entry by entry, minute by minute. The facility's own review had already established the discrepancy before inspectors arrived.
Resident D was not the only one.
The inspection report also references Resident C, whose clinical record was reviewed as part of the same investigation. Camera footage for both administrations that LPN 10 had documented for Resident C also showed she did not enter that resident's room between 11:00 p.m. and 3:30 a.m. on the nights in question. When investigators took a written statement from Resident C on October 19 at 4:15 p.m., the resident said they had not requested any pain medication on the night shift between October 7 and October 9.
The resident had not asked for it. The nurse had not given it. The record said otherwise.
CMS cited the facility under F0602, which covers misappropriation of resident property. Controlled substance medications prescribed to a resident are that resident's property. Signing them out without delivering them, whether the drugs were diverted for personal use or discarded, is a taking. The harm level was designated as minimal harm or potential for actual harm, affecting few residents.
What the designation does not capture is what it means to have Parkinson's disease and chronic pain and peripheral vascular disease, and to lie in a facility bed through the small hours of the morning without the medication a physician determined you needed every six hours.
The facility moved quickly once the pattern was identified. On October 9, the same day the discrepancy came to light, management conducted a narcotic audit of all controlled substance records across residents, looking for other discrepancies and unusual activity. Staff were educated that same day on misappropriation of resident property, with specific emphasis on medication administration. All appropriate residents were interviewed to determine whether they had received their medications. Pain assessments were completed on all non-verbal residents who could not report for themselves.
On October 10, all employees with potential access to divert medications were drug tested.
By October 15, the pharmacy had completed a 90-day audit of narcotic records and reported no additional concerns. The facility told inspectors the deficient practice was corrected by that date.
The past noncompliance was recorded as beginning October 8 at 2:00 a.m., the timestamp on the first falsified entry for the overnight hours when LPN 10's signature appeared on a record documenting a medication she had not given.
The inspection report does not say what happened to LPN 10. It does not say whether she was terminated, whether the matter was referred to law enforcement, or whether the state nursing board was notified. It does not say where the hydrocodone went.
What it says is that a nurse signed controlled substance records four times across two nights, and that a resident with Parkinson's disease and chronic pain went without their prescribed narcotic pain medication during those hours, and that the only reason anyone knows is because the cameras were running.
Resident D's physician had decided, back in July, that this person needed pain relief every six hours. The schedule existed because the need was real and recurring. The 2:00 a.m. dose was not incidental. It was there because chronic pain does not pause for the night shift.
The facility's abuse prohibition policy, a copy of which the Executive Director provided to inspectors on the morning of October 29, defines misappropriation of resident property as the deliberate misplacement or wrongful use of a resident's belongings without the resident's consent. The policy dates to June 2023.
LPN 10 had signed the narcotic records as administered. The camera showed the door never opened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clark Rehabilitation and Skilled Nursing Center from 2025-10-29 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: August 5, 2026 · Our methodology
CLARK REHABILITATION AND SKILLED NURSING CENTER in CLARKSVILLE, IN was cited for violations during a health inspection on October 29, 2025.
The inspection, completed October 29, 2025, was triggered by a complaint.
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.