Clark-Lindsey Village

In the surveyor’s words

From the most serious findings on record at Clark-Lindsey Village, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 15, 2025

  Based on interview and record review the facility failed to protect one (R7) resident's right to be free from abuse and neglect by staff members (V10, V11) out of five residents reviewed for abuse and neglect in a sample list of eight residents. R7 was not provided basic cares such as repositioning and incontinence care timely. R7 was made to cry, scream and yell out in pain as staff refused to assist and reposition R7 during incontinent cares. Findings include:R7's Electronic Medical Record documents medical diagnoses as Gastrointestinal Hemorrhage, Protein-Calorie Malnutrition, Alzheimer's Disease, Dementia, Anxiety, Difficulty in Walking, Need for Assistance with Personal Cares, Cognitive Communication Deficit, Crohn's Disease, Cervical Disc Degeneration, Diverticulitis of Large… […]

• Actual harm, isolatedF689Jul 27, 2025

  Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided during toileting for 1 (R1) of 3 residents reviewed for falls on the sample list of 4. This failure resulted in R1 sustaining multiple acute fractures involving the left humerus.Findings include:R1's diagnosis in part is documented as history of falling, retention of urine, anxiety disorder, difficulty in walking, cognitive communication deficit, acute on chronic systolic (congestive) heart failure, permanent atrial fibrillation, chronic respiratory failure with hypoxia, and pulmonary hypertension.R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of eight indicating the R1 has moderate cognitive impairment.R1's MDS admission… […]

• Actual harm, isolatedF684May 16, 2025

  Based on observation, interview, and record review the facility failed to follow physician admission orders to assess and monitor a surgical site, failed to provide a physician ordered shampoo to use over a surgical site, failed to initiate Enhanced Barrier Precautions (EBP), and failed to update the care plan. These failures resulted in a surgical infection which required additional appointments, antibiotics, a second hospitalization , and surgery for one (R1) resident out of three residents reviewed for Quality Care/Treatment in a sample list of three residents. […]

• Actual harm, isolatedF689Feb 6, 2025

  Based on observation, interview, and record review the facility failed to ensure proper wheelchair positioning to prevent a fall, failed to provide safe equipment, and failed to use a mechanical lift for transfers for one (R269) of 16 residents reviewed for accidents on the sample list of 21. These failures resulted in R269 requiring emergency room treatment after falling from a wheelchair and hitting R269's head on the floor. R269 sustained a head injury and a hematoma to the left forehead. These failures also resulted in R269 sustaining skin tears to the left and right forearm. Findings include: On 2/3/25 at 11:12 PM, R269 was sitting in a reclining wheelchair by the nurse's station. R269 had a yellowish - blue bruised raised area above the left eye. […]

• Actual harm, isolatedF689Dec 13, 2022

  Based on record review, observation and interview the facility failed to implement fall intervention of assistive devices for R1 and R2. The facility also failed to adequately supervise (R1 and R2) cognitively impaired residents with known history of falls and repeated falls, resulting in R1 and R2 sustaining falls with injuries. R1's unwitnessed fall resulted in R1 sustaining multiple fractures requiring hospitalization . R2's unwitnessed fall resulted in R2 sustaining a laceration above the right eye requiring emergency medical services of sutures and hospital admission for observation. […]