Health inspection·July 27, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 assessment dated [DATE] documents that R1 is dependent on staff for toileting hygiene tasks. This MDS also documents that R1 requires Substantial/maximal assistance from staff when going from a sitting to standing position.R1's Care Plan initiated on 07/08/2025 documents that R1 is at risk for falls related to deconditioning. This Care Plan documents that staff are to follow facility fall prevention guidelines. This Care Plan documents an intervention for certified nurse assistants to maintain proactive contact with residents to anticipate needs.R1's Fall Risk Evaluation dated 07/08/2025 documents that R1's assessment score was 17.0. A score of ten or higher indicates that R1 is at high risk for falls.R1's Incident report dated 7/15/2025 at 2:30 AM documents that V8 (Certified Nurse Assistant/CNA) reported that the resident fell on her bathroom floor. This report documents that R1 stated that she voided and was going to get a wipe and stand on her own and fell on her left arm. This report documents that the CNA stated that he was just in her room to fix her bed while she was in the bathroom. This incident report documents that R1's left arm was bent with obvious signs of deformity and bruising and that R1 could not move it and stated it was painful. Radiology results dated 7/15/2025 document that R1 sustained Findings: Acute comminuted displaced fracture involving the left humeral head/neck with soft tissue swelling. Acute comminuted displaced angulated fracture involving the proximal third shaft of the left humerus with soft tissue swelling. Impression: Multiple acute fractures involving the left humerus. On 7/26/25 at 11:46, R1 is lying flat on her back in bed and a brace is on her left arm. R1 stated she had a fall, broke her arm and it is painful. On 7/26/25 at 2:28 PM, V7 (CNA) stated that when a resident has a known fall risk they should never be left unattended when they are sitting on the toilet. On 7/26/25 at 3:08 PM, V8 (CNA) stated that he knew R1 was a fall risk and should not have left R1 alone on the toilet.On 7/26/25 at 4:04 PM, V5 (Registered Nurse/RN) stated that she would expect that all CNAs should not leave a resident unattended on the toilet if they were a fall risk. On 7/26/25 at 4:14 PM, V4 (Licensed Practical Nurse) stated that it was well known, and it is documented that R1 is at risk for falls and that R1 should not have been left unattended on the toilet. On 7/27/25 at 9:32 AM, V12 (Director of Nursing) (former-at time of incident) stated that R1's outcome would have been different if V8 (CNA) would have stayed at R1's side while she was (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 2 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 07/27/2025 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)