Inspection·February 8, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain Physician Orders for Advance Directives for three residents (R4, R5, R12) and failed to ensure the resident's right to formulate an Advanced Directive for one resident (R130). This failure affects four of eight residents reviewed for Advanced Directives in the sample list of 24. Findings include: The facility's Advanced Directives policy dated [DATE] documents, The purpose of this policy is to establish guidelines for a resident's choice about advance directives and respecting those directives. 1. The facility has defined advanced directives as preferences regarding treatment options and are included in, but not limited to: f. State of Illinois POLST (Practitioner Order for Life-Sustaining Treatment) Form - a document that identifies what medical interventions a resident wants done should they be found to have no pulse and is not breathing or what medical interventions they may want performed if they are found with a pulse and/or breathing. PROCEDURE: 1. Prior to, or upon admission, Social Services will check hospital or hospital computer system or EMR (Electronic Medical Record) for facility for current residents for completed Advanced Directives and insert them into the facility's skilled care record. Wishes will be reviewed and confirmed with resident and/or family members. 2. POLST FORM if no POLST form has been completed, upon admission, Nursing staff will provide to each resident and/or their family a copy of the State of Illinois POLST form and assist with completing as needed. a. When POLST form is completed, nursing staff to call resident's nurse practitioner/MD (Medical Doctor) for a telephone order to confirm resident's wishes and will enter orders into computer program. Form will be given to MD for signature. b. A copy of the POLST will be put in the hard chart. c. Stickers will be placed on the hard chart and on the name plate of the resident's room. i. Red stickers indicate DNR (Do Not Resuscitate. ii. [NAME] stickers indicate full code. 4. All completed Advance Directives will be filed in the resident's EMR (Electronic Medical Record). Forms will be attached in (the EMR) under the documents tab. 1.) R4's Order Summary Report dated [DATE] documents R4 was admitted to the facility on [DATE] with diagnoses including Fracture of Shaft of Right Humerus, Acute Respiratory Failure with Hypoxia, Fracture of Unspecified Part of Neck of Unspecified Femur, Atrial Fibrillation and Diabetes Mellitus. R4's POLST form is signed by V11 (R4's Power of Attorney) on [DATE] and has V12's (Physician) signature but no date that V12 signed the form. This POLST form documents R4 wishes to have no CPR (Cardiopulmonary Resuscitation) initiated. R4's Order Summary Report dated [DATE] does not document an order to confirm R4's wishes that are (continued on next page) 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 6 Event ID: 145381 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 145381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2023 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)