Clark-lindsey Village

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to ensure residents rights were honored for one (Resident R1) resident out of five residents reviewed for Resident Rights in a sample list of eight residents.Findings include: Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R1 as cognitively intact. This same MDS documents Resident R1 as requiring set up assistance with eating, oral hygiene, is dependent on staff for assistance with dressing and requires moderate assistance for bed mobility and transfers.Resident R1's Care Plan initiated does not include a focus area, goal nor interventions for Resident R1's resident's right to make her own choices. On 10/15/25 at 9:47 AM, Resident R1 was laying in her bed with her breakfast tray of food sitting on her bedside table. Resident R1 stated she just finished her breakfast. Resident R1 stated she prefers to get up out of bed 'much earlier around 7:00 AM' to eat her breakfast in the dining room. Resident R1 stated she enjoys talking with the other residents. Resident R1 stated she was told by the facility staff that the facility was 'short staffed' today and did not have enough staff to get her up earlier. Resident R1 stated The girls (staff) work hard and I understand that they are trying but I would like to get up to the dining room table for all of my meals. I don't mind this once in a while, but it has recently become the norm to have me eat breakfast in bed because of low staffing.On 10/15/25 at 10:00 AM, V19 (Certified Nursing Assistant/CNA) stated the facility did not have enough staff this morning (10/15/25) to get all the residents out of bed and out to the dining room for breakfast. V19 stated there are multiple residents who would normally go to the dining room but just can't due to lack of staff. V19 stated there are plenty of ‘bodies' but those extra staff do not provide cares for staff. V19 stated the residents should be able to go to the dining room if they choose to. On 10/15/25 at 11:30 AM, V2 (Interim Director of Nurses/DON) stated the facility does provide more than the regulatory requirement of staff to provide cares for the residents. V2 stated the residents should be provided the cares as requested and/or needed without question. V2 stated she was aware of staffing concerns on Resident R2's hall this morning (10/15), but the ancillary licensed staff (V20 Health Services Administrative Coordinator/CNA) was on the hall. V2 stated she will in-service (V20) ancillary staff to ensure resident care takes priority. V2 stated Resident R1 should have been assisted up to the dining room for breakfast if that is what Resident R2 prefers. The State Agency pamphlet dated April 2024 documents the facility must make reasonable arrangements to meet your needs and choices.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark-Lindsey Village

101 West Windsor Road Urbana, IL 61801

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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to document, follow up and resolve grievances for one (Resident R7) resident out of five residents reviewed for grievances in a sample list of eight residents. Findings include: Resident R7's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R7 as moderately cognitively impaired. This same MDS documents Resident R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. On 10/14/25 at 8:30 AM, during the entrance conference, V2 (Interim Director of Nurses/DON) stated the facility has not had any family concerns and/or grievances for the past three months. V2 stated there is no grievance log or grievance reports. On 10/14/25 at 10:20 AM, V16 (Resident R7's Power of Attorney/POA) stated on 9/7/25, V10 and V11 (Certified Nurse Assistants/CNAs) assisted Resident R7 to Resident R7's bathroom toilet. V16 stated Resident R7 was being transported from her bed to the toilet using a total body mechanical lift using a toilet sling. V16 stated during the transport back from the toilet to the bed, Resident R7 continued to have a bowel movement. V16 stated Resident R7 was not positioned correctly in the sling and was ‘screaming in pain'. V16 stated Resident R7 was about a foot away from the toilet. V16 stated V11 (CNA) then pushed a small garbage can under Resident R7. V16 stated Resident R7 was forced to have a bowel movement in a garbage can as she was screaming in pain due to poor positioning. V16 stated V16 has had multiple conversations and ongoing electronic mail (E-mail) with V2 (Interim DON). V16 stated V16 asked V2 to not have V10 and V11 CNAs in Resident R7's room and/or providing any cares for Resident R7 after the 9/7/25 incident. V16 stated both V10 and V11 have provided cares since that date (9/7) and when V2 was informed, V2 responded with ‘(V10, V11) are not (Resident R7's) primary CNAs so that is okay'. V16 stated she asked if there was someone else to speak to about ongoing care concerns and the staff ‘neglecting' Resident R7 and was told by V2 that no one else would be able to do anything. On 10/14/25 at 1:20 PM, V1 (Administrator in Training/AIT) stated she was made aware of Resident R7's family concerns on 9/7/25. V1 stated V2 (Interim DON) informed V1 that V2 is ‘taking care of that situation' and nothing else needed to be discussed and/or elevated to a grievance report. On 10/14/25 at 2:20 PM, V2 (Interim DON) stated V2 has worked ‘closely' with V16 (Resident R7's POA). V2 stated V16 has had multiple concerns about the lack of care for Resident R7. V2 stated V16's concerns were never reported to V21 (Grievance Officer) due to V2 did not think V16's concerns needed to ‘rise to the level of a grievance'. On 10/15/25 at 12:05 PM, V21 (Grievance Officer) stated grievances can be brought forward from residents, resident representatives, staff, visitors or anyone who has a grievance. V21 stated she has not received nor been made aware of V16 (Resident R7's POA) concerns. V21 stated V16's concerns would ‘rise to the level of a grievance' and should have been brought forward.The facility policy dated October 19, 2022, titled Grievance Policy documents It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. Voicing grievances is not limited to a formal, written grievance process but may include a resident's verbalized complaint to facility staff.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark-Lindsey Village

101 West Windsor Road Urbana, IL 61801

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 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and let (Resident R7) finish p****** (bowel movement/expletive) into the trash can so it didn't get on my shoe. Once (Resident R7) was done p****** (expletive), we (V10, V11) transferred (Resident R7) back to her bed and left the room. (Resident R7) kept crying and screaming. (V16) kept yelling at us (V10, V11). We had enough of it. I guess (V16) finished getting (Resident R7) cleaned up because we (V10, V11) were done with (V16). On 10/14/25 at 4:00 PM, V16 (Resident R7's POA) provided camera footage showing on 10/14/25 at 6:01 AM an unknown (CNA) provided perineal care for Resident R7, at 8:00 AM Speech Therapy provided Speech therapy with Resident R7 while Resident R7 was laying in her bed, and there were no other recordings of any staff entering Resident R7's room until 3:10 PM when V9 (CNA) answered Resident R7's call light. Through direct observations, Resident R7 was in her room and staff did not enter Resident R7's room from 10:30 AM-3:10 PM. The facility policy dated February 20, 2025, titled Abuse Prevention and Prohibition documents all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of resident property and exploitation, including abuse facilitated or enabled through the use of technology, photographing and recording of residents. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.

Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.

Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or in the deterioration of a resident's physical or mental condition. The facility staff should identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark-Lindsey Village

101 West Windsor Road Urbana, IL 61801

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

medications because the nurses won't bring them. V16 stated the facility provided packets and a gallon jug of thickener and a device for V15, V16 and V17 to crush Resident R7's medications. V16 stated the facility allows the staff to neglect Resident R7 by knowing that the staff are not providing Resident R7's cares. V16 stated V16 has had multiple conversations and ongoing electronic mail (E-mail) with V2 (Interim Director of Nursing/DON). V16 stated V16 asked V2 to not have V10 and V11 (CNAs) in Resident R7's room and/or providing any cares for Resident R7 after the 9/7/25 incident. V16 stated both V10 and V11 have provided cares since that date (9/7) and when V2 was informed, V2 responded with ‘(V10, V11) are not (Resident R7's) primary CNAs so that is okay'. V16 stated she asked if there was someone else to speak to about ongoing care concerns and the staff ‘neglecting' Resident R7 and was told by V2 that no one else would be able to do anything. On 10/14/25 at 1:20 PM, V1 (Administrator in Training/AIT) stated she was made aware of Resident R7's family concerns on 9/7/25. V1 stated V2 (Interim Director of Nursing/DON) informed V1 that V2 is ‘taking care of that situation' and nothing else needed to be discussed and/or elevated to a grievance report. V1 stated the allegation of neglect was not reported to the State Surveying Agency. V1 stated all allegations of any type of abuse should be reported and investigated.

V1 stated Resident R7's allegation was an isolated incident and has not had any other concerns brought forward by other residents or resident representatives. V1 stated the facility did not follow their abuse policy. On 10/14/25 at 2:40 PM, V2 (Interim DON) stated V16 (Resident R7's Power of Attorney/POA) e-mailed V2 on 9/7/25 reporting V16's concerns and asking for V10 and V11 to not care for Resident R7. V2 stated V10 and V11 (Certified Nursing Assistants/CNA) came to V2 a week after V16 sent V2 an electronic mail (E-mail) on 9/7/25. V2 stated V10 and V11 came to her stating there was an incident on 9/7 involving Resident R7. V2 stated V10 and V11 stated they knew V16 would ‘tattle' on V10 and V11 and they (V10, V11) were reporting themselves. V2 stated V1 (AIT) is still learning the role of Abuse Coordinator so if an allegation would need to be reported to the State Surveying Agency, V2 would be the person to do that. V2 stated she did not report this allegation to the State Surveying Agency.The facility policy dated February 20, 2025 titled Abuse Prevention and Prohibition documents the Administrator or Administrator's designee will report immediately but no later than two hours after the allegation is made to the State Agency if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark-Lindsey Village

101 West Windsor Road Urbana, IL 61801

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

provided packets and a gallon jug of thickener and a device for V15, V16 and V17 to crush Resident R7's medications. V16 stated the facility allows the staff to neglect Resident R7 by knowing that the staff are not providing Resident R7's cares. V16 stated V16 has had multiple conversations and ongoing electronic mail (E-mail) with V2 (Interim Director of Nursing/DON). V16 stated V16 asked V2 to not have V10 and V11 (CNAs) in Resident R7's room and/or providing any cares for Resident R7 after the 9/7/25 incident. V16 stated both V10 and V11 have provided cares since that date (9/7) and when V2 was informed, V2 responded with ‘(V10, V11) are not (Resident R7's) primary CNAs so that is okay'. V16 stated she asked if there was someone else to speak to about ongoing care concerns and the staff ‘neglecting' Resident R7 and was told by V2 that no one else would be able to do anything. On 10/14/25 at 10:20 AM, V16 (Resident R7's Power of Attorney/POA) stated she emailed V2 (Interim Director of Nursing/DON) on 9/7/25 following a ‘terrible incident' between V10 and V11 (Certified Nursing Assistants/CNAs) and Resident R7. V16 stated V2 responded in email to V16 on 9/8/25. V16 stated no one ever came around and interviewed V16 nor V15, V17 (Resident R7's private caregivers) to obtain a witness statement. On 10/14/25 at 3:50 PM, V11 (CNA) stated V10 and V11 reported to V2 (Interim DON) a week after ‘something happened' on 9/7/25. V11 stated V10 and V11 went to V2 due to ‘we (V10, V11) knew that V16 would ‘tattle'

on us so, we just talked to V2 ourselves. V11 stated no one had discussed the situation on 9/7 with her prior to that and no one had told her to not be Resident R7's primary caretaker. On 10/14/25 at 1:20 PM, V1 (Administrator

in Training/AIT) stated she was made aware of Resident R7's family concerns on 9/7/25. V1 stated V2 (Interim DON) informed V1 that V2 is ‘taking care of that situation' and nothing else needed to be discussed and/or elevated to a grievance report. V1 stated the allegation of neglect was not reported to the State Agency. V1 stated all allegations of any type of abuse should be reported and investigated. V1 stated Resident R7's allegation was an isolated incident and has not had any other concerns brought forward by other residents or resident representatives. V1 stated the facility did not follow their abuse policy.On 10/14/25 at 2:40 PM, V2 (Interim DON) stated V16 (Resident R7's POA) e-mailed V2 on 9/7/25 reporting V16's concerns and asking for V10 and V11 to not care for Resident R7. V2 stated V10 and V11 (CNAs) came to V2 a week after V16 sent V2 an electronic mail (E-mail) on 9/7/25. V2 stated V10 and V11 came to her stating there was an incident on 9/7 involving Resident R7. V2 stated V10 and V11 stated they knew V16 would ‘tattle' on V10 and V11 and they (V10 and V11) were reporting themselves. V2 stated V1 is still learning the role of Abuse Coordinator so if an allegation would need to be reported to the State Agency, V2 would be the person to do that. V2 DON stated she did not report this allegation to the State Agency.The facility policy dated February 20, 2025, titled Abuse Prevention and Prohibition documents when an incident or suspected incident is reported, an investigation will be done immediately. The Administrator will be informed immediately of any suspected incident and/or

an injury of unknown origin. The Administrator will appoint someone to initiate and lead an investigation.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark-Lindsey Village

101 West Windsor Road Urbana, IL 61801

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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

aware if V15, V16 and/or V17 has any medical knowledge regarding medication administration. On 10/14/25 at 2:25 PM, V2 (Interim Director of Nurses/DON) stated V2 gave approval for V16 (Resident R7's POA) to administer Resident R7's medications without a nurse being present. V2 confirmed V16 and/or V15, V17 (Resident R7) private caregivers are not licensed nurses and are not employed by the facility. On 10/14/25 at 2:50 PM, Resident R7's Benefiber and Miralax were still in the cups sitting on Resident R7's bedside table. The gallon jug of thickener, packets of thickener and pill crusher were still sitting on Resident R7's bedside dresser. V17 (Resident R7's private caregiver) stated Resident R7's Benefiber was ‘stone thick' because it had been sitting too long. V17 stated she administers Resident R7's medications daily and has done so for ‘months'. V17 stated the facility management gave Resident R7's private caregivers and V16 (Power of Attorney/POA) approval to administer Resident R7's medications. V17 stated she is not

a licensed nurse and has never had any formal training on medication administration. V16 (Resident R7's) Power of Attorney (POA) stated V20 (Health Services Administration Coordinator) ordered Resident R7's thickener and pill crusher to keep in Resident R7's room due to V16 and Resident R7's private caregivers were ‘bothering' the nurses too much by asking for Resident R7's pills to be crushed and drinks to be thickened. On 10/14/25 at 4:05 PM, V16 (Resident R7's POA) stated V2 emailed V16 on 7/22/25 stating V16 could administer Resident R7's medications without the nurse being present. On 10/15/25 at 9:30 AM, V15 (Resident R7's private caregiver) was assisting Resident R7 to eat Resident R7's breakfast in Resident R7's room. V15 was feeding Resident R7 an orange creamy substance. V15 stated this was Resident R7's Potassium liquid mixed with vanilla ice cream and thickener. V15 stated now the nurses have to mix all of Resident R7's medications.

V15 stated Resident R7's adaptive cups contained Resident R7's Miralax and Benefiber. V15 stated We (Resident R7, V15) are working

on getting all (Resident R7's) medications down. The staff say they don't have time to stay with (Resident R7). On 10/15/25 at 10:05 AM, V6 (Licensed Practical Nurse/LPN) stated she gave Resident R7's medications to Resident R7 this morning except for Resident R7's Miralax, Benefiber and Potassium. V6 stated she did not have time to wait for Resident R7 to take the Miralax, Benefiber and Potassium due to Resident R7 ‘takes forever to swallow'. V6 stated I would still be in there (Resident R7's room) if I had to do that. I don't have time for that.On 10/15/25 at 4:45 PM, V2 (Interim DON) stated licensed nurses should be administering all medications. V2 stated she did give approval for V16 (Resident R7's POA) to administer Resident R7's medications to make it ‘easier' on the nursing staff. V2 stated the facility will have to review their medication administration policy and educate staff on medication administration. The facility policy dated June 17, 2025, titled General Guidelines for Medication Administration documents the licensed nurse is to identify the resident prior to administering medications. Administer medication and remain with

the resident until medication is swallowed. Do not leave a medication in a resident's room without orders to do so. Medications will be administered by legally authorized and trained persons in accordance with applicable State, Local and Federal laws and consistent with accepted standards of practice.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark-Lindsey Village

101 West Windsor Road Urbana, IL 61801

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review the facility failed to maintain accurate medical records for one (Resident R7) resident out of five residents reviewed for Improper Nursing Care in a sample list of eight residents.Findings include: Resident R7's Minimum Data Set (MDS) dated [DATE REDACTED] documents Resident R7 as moderately cognitively impaired. This same MDS documents Resident R7 requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility and transfers. Resident R7's Physician Order Sheet (POS) dated October 2025 documents physician orders to administer:-Cephalexin 250 milligrams (mg)/5 milliliters (ml) starting 9/26/25 with no end date, give daily for recurrent Urinary Tract Infections (UTI). Prophylaxis for one year.-Cholecalciferol 25 micrograms (mcg).

Give two tablets daily.-Lactobacillus Rhamnoses give one capsule daily.-Fluconazole 150 mg tablet daily for Vaginal Candidiasis every three days.-Fluoxetine 10 mg tablet daily-Benefiber packet daily-Lisinopril 40 mg tablet twice daily-Pantoprazole 4 mg/ml suspension give 10 ml daily-Polyethylene Glycol (Miralax) powder 8.5 Grams daily-Prednisone 5 mg tablet daily-Prozac 20 mg tablet daily-Zyrtec 10 mg tablet daily-Acetaminophen 1000 mg tablets twice daily-Carvedilol 12.5 mg tablet twice daily-Diclofenac Sodium 1% external gel. Apply to Left Ankle twice daily.-Lidocaine 5% External patch. Apply to neck in the morning, remove at night.-Memantine 5 mg tablet twice daily-Miconazole Nitrate powder 2%. Apply to vaginal area twice daily.-Potassium Chloride 20 milli equivalents (mEq)/15 ml liquid. Give 15 ml twice daily.Resident R7's Medication Administration Record (MAR) dated October 2025 documents V12 (Registered Nurse/RN) and V6 (Licensed Practical Nurse/LPN) administered Resident R7's scheduled daily, and twice daily medications as ordered by the physician. On 10/14/25 at 12:00 PM, V12 (RN) stated V12 signs out medications for Resident R7 that

she does not administer. V12 stated she gives Resident R7's medications to V16 (Resident R7's Power of Attorney/POA) and/or Resident R7's private caregivers to administer Resident R7's medications. V12 stated she cannot confirm that Resident R7 receives her medications prior to V12 signing out on Resident R7's MAR as being given. On 10/15/25 at 10:05 AM, V6 (LPN) stated she gives all Resident R7's medications to Resident R7's private caregivers and/or V16 (Resident R7's POA). V6 stated

she signs out Resident R7's MAR that Resident R7's medications are being given because she ‘trusts the family to give the meds so I don't have to waste my time doing it'. On 10/15/25 at 4:15 PM, V2 (Interim Director of Nurses/DON) stated the staff should document all the work they do. V2 stated nurses should ensure the resident is receiving the prescribed medications prior to signing off that the medication has been administered. The facility policy dated June 17, 2025, titled General Guidelines for Medication Administration documents the facility nurse should return to the medication cart and document medication administration with documentation in the Medication Administration Record (MAR) immediately after administering medication to each resident. Medications will be administered by legally authorized and trained persons in accordance with applicable State, Local and Federal laws and consistent with accepted standards of practice.

Event ID:

Facility ID:

If continuation sheet