Clark-Lindsey Village: Neglect Complaint Unreported - IL
A week after the incident at Clark-Lindsey Village, the two certified nursing assistants went to the interim director of nursing on their own. One of them later told inspectors why: "We knew that V16 would 'tattle' on us, so we just talked to V2 ourselves."
V16 is the resident's Power of Attorney. V2 is the person who was supposed to investigate.
The resident at the center of this — identified in inspection records only as R7 — has private caregivers who bring supplies to the facility: packets, a gallon jug of thickener, a device to crush medications. The kind of setup that signals a family paying close attention. The kind of setup that, in this case, made no difference.
R7's Power of Attorney emailed the interim Director of Nursing the same day the incident happened. She asked that the two CNAs, identified in the report as V10 and V11, be kept out of R7's room. She got an email back the next day. Then, for weeks, nothing else happened.
No one came to interview her. No one interviewed the private caregivers who were present. No witness statements were taken from anyone outside the facility. The allegation was not reported to the state.
Both CNAs kept providing care to R7.
When the POA found out V10 and V11 were still in the room, she went back to the interim DON. The response she got: they were "not R7's primary CNAs, so that is okay."
She asked if there was someone else she could speak to. She was told no one else would be able to do anything.
Federal inspectors arrived on October 14 and 15, 2025, and interviewed nearly everyone involved. What they found was an allegation of neglect that the facility's own administrator-in-training acknowledged should have been reported to the state — and wasn't.
The administrator-in-training, identified as V1, told inspectors she had been made aware of the family's concerns on September 7. The interim DON told her she was "taking care of that situation" and that nothing needed to be elevated to a grievance report. V1 accepted that. She told inspectors the allegation was never reported to the state agency, and added: "All allegations of any type of abuse should be reported and investigated." She also said the facility did not follow its own abuse policy.
The interim DON, V2, gave inspectors her version of the same events. She confirmed the POA emailed her on September 7. She confirmed the two CNAs came to her a week later, explaining they knew the family would report them and wanted to get ahead of it. She confirmed she did not report the allegation to the state.
Her explanation for why V1 wasn't more involved: V1 is "still learning the role of Abuse Coordinator," so if something needed to be reported to the state, V2 would be the one to do it.
V2 was the one who didn't do it.
The facility's own abuse policy, dated February 20, 2025, states that when an incident or suspected incident is reported, an investigation will be done immediately, the administrator will be informed immediately, and the administrator will appoint someone to initiate and lead an investigation.
None of that happened. The administrator-in-training was told it was handled. She didn't ask again. The interim DON handled it by talking to the two CNAs after they came to her on their own, a week late, by their own admission motivated by self-interest. No investigation was initiated. No outside witness was interviewed. The state was not notified.
CNA V11 told inspectors that before she and V10 went to V2 themselves, no one had discussed the September 7 situation with her. No one had told her to stay out of R7's room.
That detail matters. The POA had specifically requested, in writing, on the day of the incident, that these two people not care for her family member. More than a month passed. The request was not honored. The reason given was that they weren't the primary caregivers, as if the assignment sheet settled the question of whether an accused aide should be in the room of the person who accused them.
What happened on September 7 is described in the inspection report only as a "terrible incident" and "something happened" — the language belongs to the people who were there, not to inspectors who documented what the facility failed to do afterward. The report does not describe the incident itself in clinical or legal terms. It does not say whether R7 was injured. What it documents is the response: an email, a week of silence, two CNAs getting ahead of a complaint, a DON who called it handled, and an administrator who took her word for it.
The POA brought her own supplies. She hired private caregivers. She emailed the same day. She followed up when the CNAs kept showing up. She asked to speak to someone else and was told there was no one else.
She was right that something was wrong. The facility's administrator-in-training agreed with her, in front of inspectors, six weeks later.
The inspection was classified as a complaint survey. The deficiency was cited under F0610, covering the obligation to report and investigate allegations of abuse, neglect, and mistreatment. The level of harm was assessed as minimal harm or potential for actual harm. The residents affected: few.
R7's private caregivers were never interviewed. Not in September, not in October, not before federal inspectors arrived and started asking questions themselves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clark-lindsey Village from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 25, 2026 · Our methodology
CLARK-LINDSEY VILLAGE in URBANA, IL was cited for neglect violations during a health inspection on October 15, 2025.
A week after the incident at Clark-Lindsey Village, the two certified nursing assistants went to the interim director of nursing on their own.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.