Inspection Report
Plan of Correction
Deficiencies: 1
Oct 21, 2025
Visit Reason
Investigation of a facility reported incident dated 9/29/2025, with review of compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The facility was found to be in compliance with applicable assisted living regulations. A technical infraction was noted regarding unsigned physician assessments, but no violation was imposed.
Deficiencies (1)
| Description |
|---|
| The establishment did not have all physician assessments signed by physicians as cited in 295.4000 a) b). |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a facility-reported incident involving a resident fall on 2025-08-28 that resulted in severe harm and death.
Findings
The facility failed to document identified fall risks and fall prevention interventions on the service plans for three residents (R1-R3) identified at risk for falls. One resident (R1) suffered a fatal fall resulting in a large subdural hematoma and death. Other residents (R2 and R3) also experienced falls with injuries. The facility did not have fall prevention interventions documented despite acknowledging fall risks.
Complaint Details
The investigation was triggered by a complaint related to a resident fall on 2025-08-28 that caused severe harm and death. The complaint was substantiated by findings of inadequate fall risk documentation and prevention planning.
Severity Breakdown
T1 Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to document a resident identified risk for falls on the Service Plan for one of three residents reviewed (R3). | T1 Violation |
| Failure to ensure fall prevention interventions were documented on the service plan for three of three residents identified at risk for falls (R1-R3). | T1 Violation |
Report Facts
Resident age: 95
Date of fall incident: Aug 28, 2025
Glasgow Coma Scale: 5
Midline shift: 2.7
Fall incidents reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Nurse Coordinator/Registered Nurse | Provided information about fall prevention handbook and resident fall incidents |
| E3 | Resident Assistant | Witnessed resident R1's fall and provided medication reminder |
Inspection Report
Annual Inspection
Deficiencies: 6
Mar 11, 2025
Visit Reason
The inspection was conducted as an annual survey of Clark-Lindsey Village, Inc. to assess compliance with state regulations including disaster preparedness, incident reporting, background checks, service plans, tuberculosis testing, and resident rights.
Findings
The facility was found deficient in multiple areas including failure to complete required fire and tornado drills, failure to report a resident injury, incomplete annual health care worker background checks, unsigned and undated service plans, failure to complete annual tuberculosis testing for residents and employees, and failure to provide services as specified in a resident's service plan.
Deficiencies (6)
| Description |
|---|
| Failure to complete all required fire drills and tornado drills as per regulation requirements. |
| Failure to report a resident injury to the Department within required timeframe. |
| Failure to complete annual health care worker background checks on all employees sampled. |
| Service plans were not signed and dated by all individuals involved in their development. |
| Failure to complete annual signs and symptoms checks for Tuberculosis and annual TB skin tests for all residents and employees sampled. |
| Failure to provide a resident services as stated in the service plan, specifically reminders to use their walker. |
Report Facts
Fire drills completed: 5
Tornado drills completed: 1
Employees without annual background checks: 7
Residents without signed service plans: 6
Residents without annual tuberculosis testing: 6
Employees without annual tuberculosis testing: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Interviewed staff member who confirmed deficiencies related to drills, reporting, background checks, service plans, and tuberculosis testing. |
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