Clark Rehabilitation And Skilled Nursing Center

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

at 2:26 p.m., indicated the following:-Camera footage for both administrations documented by LPN 10 indicated between 11:00 p.m. and 3:30 a.m., LPN 10 did not enter the resident's room.The written statement interview by Resident C, dated 10/19/25 at 4:15 p.m., indicated Resident C had not requested any pain medication on night shift between 10/7/25 and 10/9/25.During an interview on 10/29/25 at 1:48 p.m., the Regional Nurse Consultant indicated, per the video reviewed between 10/7/25 and 10/9/25 from 11:00 p.m. to 3:30 a.m., LPN 10 did not enter the resident's room to administer any medications. 3. The clinical record for Resident D was reviewed on 10/29/25 at 1:30 p.m. The residents' diagnoses included, but were not limited to, Parkinson's disease, chronic pain, depression and peripheral vascular disease.The physician's order, dated 7/30/25, indicated the resident was to receive Hydrocodone-Acetaminophen 5-325 mg every 6 hours at 12:00 p.m., 6:00 p.m., 12:00 a.m. and 6:00 a.m. for chronic pain.Review of the October 2025 controlled substance record indicated LPN 10 signed out the narcotic pain medication as administered on the following dates and times:-10/7/25 at 10:00 p.m.-10/8/25 at 2:00 a.m.-10/8/25 at 10:00 p.m.-10/9/25 at 2:00 a.m.Review of the timeline provided by the Executive Director on 10/29/25 at 2:26 p.m. indicated the following:-The video camera footage reviewed indicated on 10/7/25 at 9:13 p.m., LPN 10 entered Resident D's room with a medication cup and then exited at 9:17 p.m. From 9:17 p.m. on 10/7/25 to 3:30 a.m. on 10/8/25, LPN 10 did not enter the resident's room.-The video camera footage reviewed indicated, on 10/8/25 at 9:38 p.m., LPN 10 entered Resident D's room with a medication cup and water and exited at 9:38 p.m. From 9:38 p.m. on 10/8/25 to 3:30 a.m. on 10/9/25, LPN 10 did not enter the resident's room. On 10/29/25 at 9:47 a.m., the Executive Director provided a current copy of the document titled Abuse Prohibition, Reporting and Investigation dated June 2023. It included, but was not limited to, Policy.It is the policy.to provide each resident with an environment that is free from.misappropriation of resident property.Misappropriation of Resident.Property.Deliberate misplacement.wrongful.use of a resident's property.without the resident's consent.The Past noncompliance began on 10/8/25 at 2:00 a.m. The deficient practice was corrected by 10/15/25 after the facility implemented a systemic plan that included the following actions: A narcotic audit of all controlled records was conducted to review each resident for any discrepancies and unusual activity (10/9/25); All nursing staff were educated on misappropriation of resident property with an emphasis on medication administration and scope of practice for Certified Nursing Assistants (10/9/25); All appropriate residents were interviewed to determine if they had received all medications (10/9/25); Pain assessments were completed on all non-verbal residents (10/9/25); All employees that had potential access to divert medications were drug tested (10/10/25); The pharmacy conducted a 90 day audit for any narcotic discrepancies with no concerns (10/15/25). This citation relates to Intake 2639587 3.1-28(a)

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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

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Clark Rehabilitation and Skilled Nursing Center

517 N Little League Blvd Clarksville, IN 47129

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 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to ensure a staff followed the scope of practice for certified nursing assistants for 1 of 3 residents reviewed for services provided. (Resident B) Findings include: The clinical record for Resident B was reviewed on 10/29/25 at 11:14 a.m. The residents' diagnoses included, but were not limited to, fibromyalgia, depression and chronic pain syndrome. During an interview, on 10/29/25 at 1:48 p.m., the Regional Nurse Consultant indicated it was identified that on 10/8/25, Licensed Practical Nurse (LPN) 10 provided Certified Nursing Assistant (CNA) 11 with a resident's pain medication in a cup and CNA 11 entered Resident B's room with the medication cup. Review of the timeline provided by the Executive Director on 10/29/25 at 2:26 p.m., indicated the following: -The video footage was reviewed starting on 10/8/25 at 10:30 p.m., LPN 10 entered Resident B's room at 10:40 p.m. with a medication cup and water. LPN 10 exited the room in less than a minute and then entered another resident's room, at which time, Resident B turned her call light on. After exiting the other resident's room, LPN 10 went to the medication cart. CNA 11 entered Resident B's room, turned the call light off, exited the room and walked to the medication cart where LPN 10 was and said something to her. LPN 10 pulled open

a drawer on the medication cart and withdrew a medication cup which she handed to CNA 11 along with a cup of water. CNA 11 took both the medication cup and water into Resident B's room and came out of the room empty handed. The undated written statement from CNA 11 indicated, on 10/8/25, she had answered

the call light for Resident B who told CNA 11 that LPN 10 brought in her medication but left before she could ask for pain medication. Resident B asked CNA 11 to ask LPN 10 for a pain pill. CNA 11 found LPN 10 to let her know Resident B wanted pain medication. LPN 10 told CNA 11 that she had a feeling she was going to ask for that. LPN 10 told CNA 11 she had the pain medication right here and would CNA 11 mind to walk the medication to Resident B. CNA 11 told her she did not mind and took the medication and water to Resident B.During an interview, on 10/29/25 at 2:50 p.m., CNA 7 indicated that CNA's could not administer medication to residents as it was not in their scope of practice. During an interview, on 10/29/25 at 2:52 p.m., LPN 5 indicated that nurses could not give medications to the CNA's to administer to residents. On 10/29/25 at 2:27 p.m., the Executive Director provided a current copy of the document titled Certified Nursing Assistant (CNA) dated 10/14/25. It included, but was not limited to, Summary of Position Functions.The Certified Nursing Assistant.provides nursing and nursing related services to residents.Essential Position Functions.Provides direct care.Bathing.Dressing.Elimination/Toileting.Mobility.Transfer.Eating.Grooming.The Past noncompliance began on 10/9/25 at 10:41 p.m. The deficient practice was corrected by 10/14/25 after the facility implemented a systemic plan that included that included the following: All nursing staff were educated on medication administration and scope of practice for Certified Nursing Assistants (10/9/25); One on one education completed with CNA 11 related to scope of practice and violation of company policy for completing a task outside of the scope of practice (10/14/25). 3.1-35(g)(2)

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet