F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
Based on interview and record review, the facility failed to notify in writing, and maintain a copy in the
medical record notification to the Ombudsman of residents that were reviewed for notices before transfers.
This failure has the potential to affect all 94 Residents residing in the Facility.
Findings include:
admission and Discharge/Transfer log reviewed with multiple residents discharged /transferred.
On 5/1/24 at 8:41 AM, V1 Assistant Administrator was unable to provide any documentation the
Ombudsman was notified of resident transfers. We notify the Ombudsman of resident admits and
discharges out of the building but not if they transfer to the hospital.
Facility Application for Medicare/Medicaid, dated 5/1/24, documents 94 Residents reside in the Facility.
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
Page 1 of 4
Event ID:
145720
Printed: 05/15/2026
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
145720
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
St Clara's Rehab & Senior Care
1450 Castle Manor Drive
Lincoln, IL 62656
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and interview, the facility failed to ensure pressure ulcer wound treatment was
completed in a manner to prevent potential cross contamination of the wound for one resident (R55) of five
residents reviewed for pressure wounds, in a total sample of 39.
Residents Affected - Few
FINDINGS INCLUDE:
On 05/01/24, at 11:00 a.m., V6/Licensed Practical Nurse provided wound care for R55's stage II
(dime-sized/no drainage) coccyx area pressure wound. V6 turned R55 on R55's left side; opened R55's
incontinence brief and exposed R55's wound/no dressing noted on wound; washed the wound area with
spray cleanser and patted dry with 4 by 4 gauze; V6 allowed R55 to roll back on to the incontinence brief
with the cleansed wound touching the incontinence brief; prepared R55's medication and dressing
(Peptospermum Honey and Hydrocolloid), rolled R55 back on to R55's left side; applied the medication and
dressing (Peptospermum Honey and Hydrocolloid) leptospermum to the wound; assisted R55 back on to
incontinence brief; and then pulled up the front of the R55's incontinence brief.
At 11:10 a.m., V6 confirmed after cleansing R55's pressure wound, R55 should not have allowed R55 to
roll back over resulting in the cleansed wound touching the incontinence brief which was on R55 prior to
and during R55's wound care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145720
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
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
145720
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
St Clara's Rehab & Senior Care
1450 Castle Manor Drive
Lincoln, IL 62656
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to identify target behaviors to warrant the use of
an antipsychotic medication, failed to ensure a resident received the lowest effective dose of psychotropic
medication (R17), and failed to ensure PRN (as needed) psychotropic medication had a 14 day stop date
(R295) for two of six residents (R17 and R295) reviewed for unnecessary medications in the sample of 39.
Findings include:
1. The facility's Psychotropic Medication Policy revised 11/28/17 states, Intent: Residents are free from
unnecessary psychotropic medication use. These medications are to be given to treat a specific
condition/medical symptom that is diagnosed and documented in the clinical record. Specific
condition/medical symptoms alone are not enough to justify pharmacological use. B. Dose, Duration,
Monitoring: 1. Evaluation of pharmacological ongoing effectiveness towards therapeutic goal. 2. Evaluation
of the effectiveness of the non-pharmacological approaches prior to medication administration. 3. Quarterly
evaluation or more frequent if needed to determine if a reduction is warranted. C. Gradual Dose Reduction:
1. Residents should receive the lowest effective dose of psychotropic medication for the residents' physical,
mental, and psychosocial well-being. The Policy also documents Initial PRN (as needed) order of
antipsychotic medication should not exceed 14 days. A new order must be obtained after the physician or
prescribing practitioner believes that to extend beyond the 14 days and has documented to rationale and
indicated the rationale.
R17's Face Sheet documents R17 admitted to the facility on [DATE] with diagnoses to include but not
limited to: Unspecified Dementia with Psychotic Disturbance; Anxiety Disorder, and Depression.
R17's current Care Plan documents R17 takes an antipsychotic medication related to psychosis. This same
Care Plan does not document R17's specific behaviors related to R17's antipsychotic use.
R17's Note to Attending Physician/Prescriber dated 2/7/24 documents a pharmacy recommendation to
decrease R17's Seroquel Antipsychotic medication from 50 mg to 25 mg in an effort for a dose reduction.
This same note documents V5 (R17's Physician) signed and agreed with the recommendation.
R17's Physician Order Sheet dated July 2023-May 2024 documents orders for Seroquel (Antipsychotic)
25-50 milligrams/mg by mouth at bedtime for unspecified Psychosis with R17 currently receiving 50 mg by
mouth at bedtime.
R17's Medication Administration Records (MAR) dated February 2024 documents between 2/1/24 and
2/22/24 R17 received Seroquel 50 mg by mouth nightly. This same MAR dated 2/23/24-2/29/24 documents
R17 received Seroquel 25 mg by mouth nightly. The MAR for the entire month of February 2024 documents
NO behaviors exhibited by R17 were observed.
R17's MAR dated March 2024 documents between 3/1/24 and 3/26/24 R17 received Seroquel 25 mg by
mouth nightly. This same MAR documents between 3/27/24-3/31/24 R17 received Seroquel 50 mg by
mouth nightly. The MAR for the entire month of March 2024 documents NO behaviors exhibited by R17
were observed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145720
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
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
145720
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/03/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
St Clara's Rehab & Senior Care
1450 Castle Manor Drive
Lincoln, IL 62656
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R17's MAR dated 4/1/24-4/30/24 documents R17 received Seroquel 50 mg by mouth nightly for the entire
month. This same MAR documents NO behaviors exhibited by R17 were observed.
R17's Behavior Tracking Logs dated 12/30/23-5/1/24 documents No Behaviors Observed for this period.
On 4/30/24 at 11:10 AM, R17 was sitting up in a chair in R17's bedroom. R17 was calm, alert, oriented and
able to answer questions well. R17 stated R17 could not recall why R17 was on the antipsychotic
medication Seroquel. R17 stated, I think I was angry when I first came in, so they put me on Seroquel. I
have Dementia too. That might also be why. Around 12:30 this same day, R17 was observed ambulating
independently throughout the facility, socializing, and interacting with other residents well. No abnormal
behaviors were observed.
On 5/2/24 at 8:52 AM, V4 (Licensed Practical Nurse) stated that R17's Seroquel dose was decreased from
50 mg to 25 mg in February 2024 in response to V5's (R17's Physician) physician response to a Pharmacy
Recommendation. V4 stated R17's Seroquel dose was increased back to 50 mg from 25 mg because R17
and V11 (R17's Power of Attorney) refused the reduction. V4 denied that R17 exhibited behaviors to justify
the medication dose increase.
On 5/1/24 at 3:14 PM, V7 (Regional Director of Operations) verified R17's behavior tracking logs were not
specific to R17's behaviors for antipsychotic use and verified R17's behavior logs did not document any
behaviors to warrant the use of R17's antipsychotic medication. V7 stated psychotropic medications cannot
be increased for family preference if there are no associated behaviors.
On 5/1/24 at 3:20 PM, V1 (Assistant Administrator) denied that R17 exhibits any behaviors to justify the use
of an antipsychotic medication.
2. R295's Electronic Medical Record (EMR) document R295's diagnosis to include: Unspecified Dementia;
Gastro-Esophageal Reflux Disease, Anxiety Disorder, Hallucinations, and Hypertension.
R295's EMR document Physician's Order, dated 4/10/24, Lorazepam Oral Tablet 0.5 MG (milligrams). Give
1 tablet by mouth every 6 hours as needed for Anxiety. indefinite.
On 5/2/24, at 11:55 a.m., V8/Regional Nurse Consultant confirmed the PRN medication should have had a
14-day stop date.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145720
If continuation sheet
Page 4 of 4
