The Illinois Department of Health has cited and fined Jerseyville Nursing & Rehab Center when staff failed to properly assess, document, and implement new interventions following multiple falls of a severely cognitively impaired resident, resulting in a delay in diagnosing and treating the resident’s broken hip. The resident suffered for five days with an undiagnosed hip fracture until X-rays were finally ordered, revealing a broken left trochanter that required hospitalization.

The case involves an elderly resident with multiple medical conditions including dementia, tremors, vertigo, and a history of falls. According to facility records, the resident was documented as “severely cognitively impaired” requiring “maximum/substantial assist for activities of daily living (ADLs) and mobility.” The resident’s care plan identified her as “at risk for falls” and included numerous interventions such as toileting assistance every two hours, non-skid socks, standby assistance when ambulating with walker, frequent rest periods, and placement in common areas for increased supervision.

Despite these interventions, the resident experienced a series of falls. On the first documented fall, the resident’s Power of Attorney (POA) brought to staff’s attention that the resident had “abrasion/bruised area to left forehead and an area into left hairline and that the resident complains of pain to head and to left upper hip down into left upper thigh and left foot slightly rotated inwards.” The POA noted that when assisting the resident from the toilet, the resident “started complaining of pain left hip and had a difficult time getting up.” The resident was sent to a local hospital for evaluation, with the hospital reportedly finding “everything was negative” based on CT scans and X-rays.

Four days later, another incident occurred when the resident was “found lying on the bathroom floor on her back with her hands behind her head.” Notes indicated “no new injury” though “bruising continues to right arm and some areas on forehead.” During the process of lifting the resident, staff documented that “she begins to yell and resist care” and “begins to shake all over.” The resident was again transported to the local hospital, with follow-up notes indicating “no injuries and range of motion within normal limits.”

Three days after this second hospital visit, staff documented that the resident was “displaying difficulty with ambulation and transfer this shift as well as bruising to the left hip and thigh area and complaints of pain.” The resident’s daughter expressed concerns that no X-rays had been completed during the previous hospital visit. Only then did the nursing home order X-rays of the left hip, leg, and ankle.
The next day, the resident was found “sitting on wheelchair pedals” with the roommate reporting that “she sat on her pedals hanging onto the arms of the wheelchair.” Again, staff documented “no new bruises” and “no complaints of pain, discomfort, or facial expressions.” However, the following day, progress notes finally acknowledged that the resident “has a broken Trochanter left hip.” The resident’s daughter wanted the resident to see a specific physician who would not be available until a later date, but staff noted the resident was “getting worse, and having more pain.” Later that day, the resident was noted with “increased pain to left hip” and was finally sent to the local hospital for “evaluation and treatment.”

During the investigation, the Director of Nursing (DON) initially stated that she did not think the hip fracture was related to the documented falls, suggesting there might have been an “unknown injury.” Later, the DON acknowledged that “we had been trying to keep her in her chair because she was getting some medication for pain but her daughter kept walking her and would complain of pain so that is why we ordered the x-ray.” The DON confirmed that “there should be an intervention after every fall or incident, and they should be on the care plan,” yet the investigation found no documentation of new interventions for the falls.

Notably, the facility’s own fall policy, which had not been updated since 2017, clearly states that “any change of plane should be considered a fall” and “a fall without injury is still a fall.” The Regional Director confirmed this definition during the investigation. The policy further states that falls should be managed through “prevention, investigation, and implementation, and evaluation of intervention,” yet there was no evidence these steps were properly followed for the resident’s falls.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Arc At Hickory Point when a certified nursing assistant transferred a severely cognitively impaired resident using a mechanical lift without the required second staff member present, resulting in the resident suffering a displaced fracture of the right femur. The improper transfer violated the facility’s own policy and led to the resident needing surgery to repair the broken bone.

The incident occurred when a resident began yelling to “get up” during the night. According to nursing notes, the resident had been in a “normal mood without pain” earlier in the evening when receiving medications. Around midnight, a Certified Nursing Assistant (CNA) responded to the resident’s calls and used a mechanical lift to transfer the resident from bed to wheelchair without assistance from a second staff member. The facility’s policy clearly states “when using a mechanical lift for transfers two staff members need to be present.” The resident’s care plan also specifically documented that the resident “transfers with a mechanical lift and assistance of two people.”

After the transfer, the resident began “yelling and screaming that her leg hurt” and was brought to the nurses’ station. The nurse assessed the resident and found the right leg appeared “displaced” and “dangling.” The resident was unable to move the right lower extremity independently. Emergency services were called, and the resident was transported to the hospital where X-rays confirmed an “oblique displaced fracture of the distal right femur.” The resident underwent surgery for “retrograde nailing” to repair the fractured femur.

When interviewed, the CNA admitted to transferring the resident alone using a sit-to-stand lift. The nurse stated, “I can’t say that the resident was transferred incorrectly because I was not in the room during the transfer,” but confirmed the leg was “clearly displaced” when preparing the resident for transport. An orthopedic surgeon at the hospital reportedly told the resident’s family member that the spiral fracture “may have been caused during the resident’s transfer at the facility,” though he later expressed reluctance to provide opinions that could be used against the facility. The family member expressed frustration, stating he “never received answers as to what happened” and was concerned that the resident “went to bed fine, and then at 1:00 AM was screaming and in pain.”

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Alden Park Strathmoor when a resident fell between her bed and wall-mounted radiator, causing her right foot to become trapped under the hot radiator. The resident suffered a second-degree burn to the top of her foot that required hospital treatment, including surgical debridement of the wound.

The incident occurred when the resident fell from her bed and became trapped between the bed and the wall-mounted radiator in her room. According to the facility’s documentation, staff found the resident “on the floor of her room with her right leg stuck under the heater.” The resident was discovered to have a burn to the top (dorsal area) of her foot.

On the same day as the fall, the facility received abnormal lab results for the resident and sent her to a local hospital for evaluation. During her hospital stay, the resident was diagnosed with multiple conditions including a high blood potassium level, Influenza A, urinary tract infection (UTI), and a second-degree burn to her right foot. Hospital records showed that the burn was severe enough to require wound debridement, a procedure that removes damaged tissue to promote healing.

When interviewed about the incident, the resident clearly recalled what happened: “I got burned. I fell and my foot got stuck under the heater. My bed used to be over by the wall with the heater. I stuck in between there when I fell. I couldn’t get up. My foot was burning.” Her account demonstrates she was aware of the pain and danger but was unable to free herself.

The nurse who discovered the resident provided additional details: “I heard her calling for help. I found her on the floor of her room, stuck between the bed and the radiator on the wall. Her right foot had gotten stuck in the radiator. When I pulled her foot out from under the radiator, the top of her foot was bright red.”

After returning to the facility, the resident was assessed by the facility’s wound physician. The physician documented a “new wound to right foot. Burnt her foot via radiator.” The wound assessment measured the burn at 9 centimeters by 5.5 centimeters by 0.1 centimeters, covering the top of her right foot and the first two toes. When interviewed, the wound physician confirmed he was treating the resident for a “second degree burn to her right foot caused by the radiator in her room.”

Significantly, the facility’s Maintenance Director revealed that there was no system in place to monitor or control the temperatures of the wall radiators in resident rooms. He explained, “We don’t check the temperatures of the radiators. We can’t control the wall radiators. They just kick in when the forced air heating system of the facility has trouble maintaining room temperatures. When it’s colder outside and the forced air system has trouble keeping the temperatures up, the wall radiators will work longer and harder to help keep the room temperatures where they need to be.”

The Maintenance Director also confirmed that wall radiators were located in every resident room in the facility, potentially placing all 160 residents at risk for similar injuries. The Administrator acknowledged that the facility did not have a policy or process for monitoring the temperatures of the wall-mounted radiators.

During an observation conducted by state inspectors, the resident was seen in bed with her right foot propped up on a pillow, with a large gauze dressing around her right foot and ankle, indicating ongoing treatment for the serious burn injury.

The facility’s failure to implement safety measures regarding the wall-mounted radiators—such as temperature monitoring, protective barriers, or bed placement guidelines—created a dangerous environment that led to this resident’s painful injury and subsequent hospitalization.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Villa Health Care East when staff left a resident with severe dementia and high fall risk alone on the toilet despite her inability to safely transfer herself or use a call light. The resident attempted to return to bed without assistance, fell, and suffered a left hip fracture that was not properly identified for two days.

The resident in question had been recently admitted to the facility with diagnoses including dementia, Lewy Body Dementia, and high risk for injury related to falls. Her facility assessment documented that she was a high fall risk with severely impaired cognition, occasionally incontinent of urine, and required substantial to maximum assistance with toilet transfers.

The resident’s care plan specifically noted, “Anticipate and meet the resident’s needs” and “Be sure my call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.”

According to the facility’s fall investigation, a Certified Nursing Assistant (CNA) summoned a nurse after finding the resident “lying on (Right) side in front of toilet.” When asked what happened, the resident stated, “I tried to get up.” The facility documented the root cause as: “Resident new to facility and attempted to walk back to her bed from her toilet without calling for assistance.”

Two days after the fall, hospital records show the resident was diagnosed with a “mildly displaced intertrochanteric fracture with resultant varus angulation” of the left hip. The hospital history noted that the day after her fall, the resident “worked with physical therapy she was able to [do a] few steps she was hunched over but still was able to do some therapy” before her condition worsened the next morning when “she was having difficulty with legs.”

Staff interviews revealed significant inconsistencies in care practices. A Licensed Practical Nurse (LPN) from the day shift stated, “we did not leave her on the toilet alone because they all knew she was a high fall risk.” This nurse also mentioned there was a white board in the resident’s room noting her high fall risk status.

The nurse who assessed the resident after her fall stated she found the resident “lying on her right side on the floor” with “a scrape above her right eyebrow.” The nurse performed range of motion tests of her arms and legs and found “no issues.” Notably, this nurse admitted she “did not know why [the CNA] put her on the toilet and then left the room, maybe to help another resident.” The nurse also stated she did not think the resident “knew how to use the call light or what it was for because of her dementia.”

Another CNA who cared for the resident the day after the fall observed that the resident “was having pain in both of her hips and in her back” and had “facial grimacing when she transferred.” This CNA emphasized that she “would not leave [the resident] unattended on the toilet nor would she never depended on [the resident] using her call light when she needed to get off of the toilet and that she would stay with her until she was finished.”

The nurse who ultimately identified the hip fracture described finding the resident’s “left leg was rotated outward and shortened,” classic signs of a hip fracture. This nurse immediately called the doctor and the resident was sent to the emergency room. The nurse stated the resident “should have never been left alone on the toilet” and that “with [the resident’s] dementia she would not know when or how to use the call light.”

A Licensed Physical Therapy Assistant who worked with the resident the day after her fall confirmed the resident “could not safely transfer herself on or off of the toilet” and while she “could hold a call light,” the therapist “did not think she would understand how to use it.” The therapist stated that “from a safety standpoint someone should have stayed in the bathroom with her.”

The Director of Nursing, when asked if the resident should have been left unattended on the toilet given her high fall risk, simply answered “no.” When asked how staff, including agency staff, would know who is at high risk for falls and what interventions are needed, the Director stated “agency should check the residents care plan and also when they get report from the previous shift, they should be let known.”

The facility’s Fall Assessment and Management Policy states, “It is the policy of this facility to assess each resident’s fall risk on admission, quarterly and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk. Factors related to the risk will be addressed and care planned.”

Despite the clear policy, the resident’s documented high fall risk, and her severe cognitive impairment, staff failed to provide the supervision necessary to prevent this serious injury.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Nature Trail Health & Rehab when staff failed to properly implement fall prevention interventions for a high-risk resident with dementia, resulting in two falls within six days of admission that caused a hip fracture requiring surgery, after which the resident never returned to the facility and died while in hospice care.

The resident in question was admitted to the facility with several serious health conditions, including unspecified dementia, weakness, and atrial fibrillation. With moderately impaired cognition, he was immediately identified as a “high fall risk.” The facility developed a care plan with interventions including bed and chair alarms from admission day, and later added precautions such as “assist to toilet prior to laying down” and “mat at bedside when in bed” after his first fall.

Despite these documented precautions, the resident experienced two falls within just six days of being admitted to the facility. The first fall occurred while he was eating dinner in his room. A Certified Nursing Assistant reported hearing “a loud noise and ran to his room and found him on the floor.” The resident’s roommate stated he witnessed the resident hit his head when he fell. The CNA observed that “there was no fall mat observed in the room and the resident did not have an alarm sounding,” even though bed and chair alarms had been ordered for him.

Following this first fall, the resident was sent to the emergency room for evaluation, particularly because he was on blood thinners, which increased his risk of internal bleeding from any trauma. The root cause of the fall was identified as the resident attempting “to stand up out of bed unassisted and fell, hitting his head.”

Just two days later, the resident experienced a second fall. A nursing note documented that he “slid out of his bed onto his bedroom floor” at 6:30 in the morning. Initially, the resident didn’t report any pain after this fall and was moved to his wheelchair with the assistance of two staff members. However, by 11:00 AM, he began “complaining of pain to left hip.” Later that same day, he also reported shoulder pain. The facility physician ordered X-rays of both areas.

The X-ray results, received in the early morning hours of the following day, revealed a left intertrochanteric fracture—a serious break near the top of the femur (thigh bone). The resident was transferred to the hospital, where a CT scan ruled out head and spine injuries, but an orthopedic surgeon confirmed the hip fracture and recommended surgical repair. A “Brief Operative Note” documents that the resident underwent an “Open Reduction Internal Fixation of the left hip” (surgical procedure to repair the broken bone using metal hardware).

Tragically, the facility administrator later stated that after the second fall and subsequent hospitalization, the resident “never returned to the facility as planned due to going on hospice and expiring at the hospital.” This suggests the resident’s condition deteriorated significantly after the hip fracture, ultimately leading to his death.

When investigators interviewed the resident’s roommate, who was alert and oriented, he stated “the alarm did not sound for either of the falls.” He remembered seeing the resident getting up and being “all wobbly” but was unable to help because he himself couldn’t walk.

The Director of Nursing explained that Certified Nursing Assistants are supposed to “check placement and function at the start of each shift of resident’s bed/chair alarms.” She stated she was “unsure why the alarm did not sound after each of the falls” and confirmed the alarm “should have been placed both in the chair and in the bed.” Multiple CNAs confirmed they were responsible for checking “placement and function every shift for alarms.”

The circumstances of both falls suggest serious lapses in the implementation of the resident’s care plan. Despite being identified as a high fall risk with orders for alarms, the alarms either weren’t properly installed or weren’t functioning during critical moments. The resident was able to attempt transfers independently despite his cognitive impairment and physical weakness, without the alarm system alerting staff in time to intervene.

These failures ultimately contributed to life-changing injuries for the resident, who sustained a serious hip fracture requiring surgery, and never returned to the facility before his death.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Bethany Rehab & Health Care Center when a staff member failed to properly assist a resident during a transfer from wheelchair to bed, resulting in a fall that caused multiple fractures to the resident’s knee and changed her mobility status.

The resident in question had been admitted just days earlier, a woman with a history of falls and notable weakness, particularly in her legs. Despite these challenges, she maintained her cognitive sharpness—alert, aware, and able to advocate for herself.

On the night of the incident, the resident had stayed up later than usual. “I should not have stayed up so late,” she would later recall. As the hour grew late, she needed to get into bed. According to the resident’s assessment, she required maximum assistance for mobility and transfers due to the weakness in her knees. Her care plan specifically indicated she needed significant help to move from sitting to standing positions.

A young Certified Nursing Assistant (CNA) entered the room to help with the bedtime routine. What happened next would become a matter of conflicting accounts.

The resident’s story was clear and unwavering: “While transferring myself into bed, my knees gave out and I fell forward onto my knees,” she explained. “The CNA was in the room but was just standing there and did not help me in any way.” According to the resident, no safety belt was used, and no proper assistance was provided.

The CNA, however, told a different tale. “I was advised by other aides to transfer the resident with a gait belt, and she was a one-person assist,” the aide insisted. “I had the gait belt around her and was transferring her from the wheelchair to the bed. During the transfer, the resident did not want to stand up so I was standing behind her holding onto the gait belt and helped her stand up, then moved the wheelchair out of the way. As she was pivoting her knees gave out and I lowered her to the ground on her buttocks.”

The nurse who responded to the scene added another perspective. Upon entering the room with the CNA, she found the resident sitting on the floor, alert and oriented. Notably, the nurse “did not recall seeing the gait belt around the resident” when she entered the room. Only after the assessment did she observe the CNA place a gait belt around the resident to help get her into bed.

Initially, there appeared to be no injury. The resident had no complaints of pain at the time. But days later, when the resident returned from a scheduled orthopedics appointment for an unrelated matter, she mentioned right knee pain. A diagnostic scan revealed the hidden damage: a fracture to the right knee.

Further imaging confirmed “age-indeterminate fractures of the distal femur just proximal to the knee prosthesis and at the superior aspect of the patella (kneecap).” The report specifically noted that these injuries “correlate with timing of trauma and pain”—connecting them directly to the fall incident.

The Director of Nursing at the facility was forthright in her assessment of the situation. After speaking with the resident and reviewing the evidence, she stated she “did believe the resident, and the transfer occurred without a gait belt, resulting in the resident falling and fracturing her leg.” She found the CNA’s statement “to be untruthful regarding the events that took place.”

The consequences for the resident were significant. Because of the fracture, she became non-weight bearing and required a mechanical lift for all transfers—a much more restrictive intervention than her previous level of care. When asked about the facility’s policy on gait belt transfers, the Director of Nursing admitted there was no formal policy, saying only that “the facility follows best practice when doing gait belt transfers.”

As the resident sat in her wheelchair weeks later, now wearing a brace on her right leg and with a mechanical lift sling positioned beneath her, the lasting impact of that night’s events was evident. A preventable accident had resulted in increased dependency and a painful fracture—all because proper transfer techniques and safety precautions weren’t followed.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Aperion Care Niles when staff failed to provide proper supervision and safety measures for a fall-risk resident who was left alone in her room without proper footwear and with her walker out of reach, resulting in a fall that caused a subdural hematoma requiring hospitalization.

The resident in question suffered from multiple health conditions including diabetes, difficulty walking, malnutrition, and a history of falling. This resident had moderately impaired cognition and needed assistance with basic activities like eating and moving between bed and chair.

On the day of the incident, the resident had gone out for a medical appointment with her son. When they returned to the nursing home, it was later than usual. Instead of taking the resident to the dining room where she typically ate under supervision, staff served her dinner in her room. The resident was seated in her wheelchair with the call button within reach, and she was instructed to call for help if she needed anything.

What happened next would prove critical – the Certified Nursing Assistant assigned to watch over the resident went on break. During this time, the resident attempted to stand up from her wheelchair. There were several factors working against her safety: her walker had been placed far away by the closet where she couldn’t reach it, she was wearing only socks without proper shoes, and there was no staff member present to supervise or assist her.

The resident lost her balance and fell face-first onto the floor. Another nursing assistant heard moaning coming from the room and discovered the resident lying on her stomach with a bruise on her forehead and blood on the floor. Staff quickly notified the nurse, who was working on a different floor at the time.

When the nurse arrived and assessed the situation, he found the resident on the floor with food still sitting on the table, indicating she had fallen while trying to move around during or after her meal. The resident had suffered a visible injury to her forehead. Following facility protocol, the nurse contacted the doctor, who ordered the resident to be transferred to the hospital.

At the hospital, doctors performed a CT scan that revealed an acute subdural hematoma – bleeding between the brain and its outer covering. The hospital physician noted that the resident was drifting in and out of consciousness, complaining of neck pain, and unable to answer questions coherently. After several days of hospitalization, the resident was returned to the nursing facility.

In the aftermath of this serious incident, nursing home leaders acknowledged that the fall could have been prevented through proper supervision. Multiple staff members admitted that if the resident had been placed in the dining room or near the nurses’ station for closer monitoring, if her walker had been kept within reach, or if she had been wearing proper footwear instead of slippery socks, the fall might not have occurred.

The facility’s own fall prevention policy emphasized the importance of keeping assistive devices like walkers within reach and ensuring residents wear proper non-skid footwear. Yet in this case, both of these basic precautions were overlooked.

The nursing home’s failures in this case represent a troubling pattern seen in many long-term care facilities – basic safety protocols that exist on paper but aren’t consistently followed in practice. Despite knowing the resident’s high fall risk and having documented a history of previous falls, staff made a series of critical errors: serving her in an isolated location rather than a supervised common area, leaving assistive devices out of reach, failing to ensure proper footwear, and not providing adequate supervision when the assigned caregiver went on break.

These shortcomings point to potential issues with staffing levels, training effectiveness, and the facility’s culture of safety. While corrective measures were implemented after the incident, they came too late to prevent a potentially life-threatening brain injury to a vulnerable resident who depended on the facility for protection.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Aperion Care Burbank when a staff member attempted to turn a paralyzed resident alone instead of with the required two-person assistance, resulting in the resident falling to the floor and sustaining a head injury that required a trip to the ER.

The resident in question had diagnoses of Paraplegia, Complete, Dementia, Major Depressive Disorder, Mononeuropathy of Bilateral Lower Limbs, Cataract, Hemiplegia and Hemiparesis Following Cerebral Infarction, Contracture, and Immobility Syndrome (Paraplegic).

The resident’s care assessment indicated cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3. The resident was noted to be “dependent on staff for toileting hygiene, sit to lying or lying to sitting on side of the bed and transfers.”

The resident’s care plan specifically designated that the resident “requires assistance with bed mobility related to weakness” with interventions that include “provide assist of 1-2 staff as needed.” A progress note clearly documented that the resident “is a 2 person assist with bed mobility.”

The incident in question occurred during the early morning hours when a Certified Nursing Assistant (CNA) was attempting to change the resident’s diaper. According to Fire Department records, “the patient was being changed and cleaned in bed when she was rolled out. Patient hit her head on the floor when she fell.” Hospital records confirmed this account, noting that the resident “states nurses were changing her diaper and rolled her over and she kept rolling and fell to the ground.” As a result, the resident sustained “a frontal hematoma and laceration requiring glue to close,” as well as “pain in right knee with hematoma over right tibial tuberosity.”

When interviewed, the resident provided a clear account of the incident: “The girl was turning me and was pushing me, and I kept saying stop, you’re going to push me out. The girl kept pushing, and next thing I knew, I fell to the floor.” The resident added, “It hurt my shoulder and my head.”

Multiple staff members confirmed that the resident required two-person assistance for turning. One CNA stated, “The resident needs 2 persons to turn her. The resident can’t help with positioning and is heavy, and 2 people are needed to turn her.” Another CNA confirmed that the resident “is 2 persons assist for cares” and “can’t roll out of the bed, and she can’t help to turn.” This CNA also noted that when he returned to work after the incident, the resident’s “face was swollen, all on the right side was swollen.”

A Restorative Aid who worked regularly with the resident confirmed, “For the resident’s bed mobility, I go in and I turn her side to side, with another person at all times… The CNA and I are doing all the work to turn her, she is dependent on staff. I have never seen her turn or try to roll. In all the time I have worked with the resident, she has never tried to roll or initiate the roll in bed.”
In this case the facility failed to ensure that two staff members assisted with turning the resident as required by the resident’s care plan. This failure directly resulted in the resident’s fall and subsequent injuries.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined The Arc at Streator when staff failed to implement appropriate interventions for a high-fall-risk resident who experienced four falls within a month, resulting in a hip fracture requiring surgical repair.

According to the facility’s Fall Prevention Program, the facility is responsible for “assur[ing] the safety of all residents in the facility, when possible” through “assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices.”

The resident in question was documented as being at risk for falls. Despite this known risk, the resident experienced four falls within a month. The first fall occurred when the resident “was sitting on the floor next to her bed” and stated “she was trying to go to breakfast” but “didn’t realize it was bedtime.” The assessment noted that “safety interventions are already in place” and no new interventions were implemented.

Two days later, the resident fell again and “was sitting on the floor with her back against her roommate’s recliner.” The resident explained she “was walking out of the bathroom without her walker or wheelchair, tripped over the catheter bag.” This fall resulted in “a skin tear 3.7cm (Centimeters) on her right shin and a 5cm by 1.1cm skin tear on her right forearm.” Again, “no new immediate fall interventions were put into place.”

Two days after the second fall, the resident fell a third time. She “was yelling out for help” and found “sitting on her buttocks on the floor.” The resident stated “she was getting up for lunch and fell.” Her “call light was off” and her “wheelchair with her catheter bag was next to” her. This fall caused “a 2cm by 2cm lump and a bruise to her left forehead,” “a 0.5cm by 0.2cm bruise to her left elbow,” and “a 4cm by 4cm skin tear to her left lower extremity.” After this third fall, an intervention was finally implemented: “to keep [the resident] within nurses’ sight.”

However, about two and a half weeks later, the resident fell a fourth time. Three nurses “were at the southwest nurses’ station when they heard a loud yell,” and found the resident “lying on her back on the floor in the middle of the southeast hallway.” The resident indicated “pain to her left hip area with movement.” The resident’s Power of Attorney requested that [the resident] be sent to the emergency room for an evaluation. X-rays revealed an acute minimally displace fracture involving the left femur lesser trochanter with suggestion of extension through the femoral neck. The resident underwent surgery for left hip cephalomedullary nailing.

When interviewed, a Registered Nurse stated that “attempts were made to keep [the resident] within sight while she is up in the chair” but wasn’t sure “why [the resident] was left alone in the hall.” A Certified Nursing Assistant (CNA) reported that the resident “was attempting to get up and down most of the morning” and “was confused, mumbling for a few days prior to her fall.” The CNA explained the staffing challenges: “staff try to sit with [the resident], but it is hard to do when staff are on breaks, and call lights are going off.” The CNA confirmed she “was the only one CNA on the floor at the time of the fall” while the nurses “were at the nurses’ station for report and shift change.”

Another Registered Nurse stated that when the resident “is anxious, attempts are made to keep her at the nurses’ station and within arm’s reach” but verified that the resident “was unable to be redirected.” The Director of Nursing admitted that the resident’s Fall Risk Assessment “is inaccurate” and verified that the resident “was a high risk for falls.” Another CNA confirmed that the resident “was wandering everywhere on the day she fell” and that “during breaks there is only one CNA on the unit to answer call lights and provide care.”

This case highlights the broader issue of chronic understaffing in nursing homes throughout the state of Illinois. When facilities operate with insufficient personnel, residents requiring close supervision—particularly those at high risk for falls—are left vulnerable. As evidenced in this incident, a single CNA was expected to monitor multiple residents while simultaneously responding to call lights and providing essential care. This staffing shortage creates impossible situations where even well-intentioned caregivers cannot implement required safety interventions, leading to preventable injuries that significantly impact residents’ quality of life and create additional healthcare costs.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Aliya of Homewood when staff failed to provide proper toileting assistance to a high-risk resident with dementia, resulting in two falls with the second causing a head injury requiring hospitalization.

The resident in question suffers from diagnoses including history of falling, altered mental status, unspecified dementia, psychotic disturbance, and muscle wasting. She scored 3 on the Brief Interview for Mental Status (BIM) and 20 on the falls risk assessment, putting her at high risk for falls.

The resident had experienced two falls at the facility. The facility’s care plan for the resident noted her high fall risk related to cognitive deficit and impaired mobility, and was revised after her first fall to include “Staff to provide prompt toileting assist before and after meals and PRN [as needed].”

The Progress notes for the resident documented that she was found sitting on the bathroom floor with a wet brief, and later was observed on the floor with a head injury.
Multiple staff members provided accounts of the incidents. A Certified Nursing Assistant (CNA) stated she wasn’t assigned to the resident but helped return the resident to bed, noting she had seen the resident in bed about half an hour before the incident. Another CNA who was assigned to the resident stated that when she checked on the resident early morning, the resident wasn’t in her room because she was in therapy. When she returned around 7:00am, the resident was in bed, and the CNA informed her she would return with breakfast. This CNA admitted she didn’t offer toileting assistance because the resident was “an incontinent resident.” She later helped put the resident back to bed after the fall and discovered the resident’s diaper was soiled with both urine and feces.

A Registered Nurse reported finding the resident sitting on the floor with a head injury. The resident couldn’t explain what happened. After assessment, the nurse notified the family and doctor, who ordered the resident be sent to the hospital. An Occupational Therapy Assistant confirmed taking the resident to therapy early morning and bringing her back to her room.
The Assistant Director of Nursing stated the expectation that “staff to offer toileting and incontinence care whenever they round on the residents.” Sadly, in this case, the resident suffered a serious injury when proper toileting assistance, as required by her care plan, was not provided.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Serenity Estates of Lincolnshire when staff failed to supervise a resident with dementia walking to their room after dinner, resulting in an unwitnessed fall that caused severe brain bleeding. The resident, who had a documented history of falls and required supervision for walking, was found on the floor with a head injury and had to be admitted to the Intensive Care Unit for treatment of subdural and subarachnoid hemorrhages.

According to facility records, the resident “was seen walking towards her room with her rolling walker” and “was later found lying flat on her back on the floor” with “a bump on the back of her head.” The situation was particularly concerning because the resident had clear care instructions requiring supervision for all walking activities, especially after meals, due to previous falls and multiple risk factors.

The resident’s care plan explicitly outlined significant fall risks, including “confusion and impaired memory,” “abnormalities of gait and mobility,” and “unsteadiness on feet.” The facility’s own assessment showed the resident required “Supervision or Touching assistance” for even basic movements like standing up, transferring between surfaces, and walking any distance.

Particularly troubling was that this incident occurred despite enhanced safety measures put in place after a previous fall. The facility had specifically added a requirement to “Assist the resident to walk to her bedroom before and after meals.” When investigating the incident, staff noted that “drawers were still open” in the resident’s room, leading them to assume the resident had attempted to retrieve something and lost their balance.

The Director of Nursing’s comments revealed a serious lapse in care protocols, as staff were aware the resident had been walking alone – they reported the resident “was last seen walking toward her room after dinner.” This admission suggests a troubling gap between documented care requirements and actual practice, as staff apparently observed the resident walking unassisted but did not intervene as required by the care plan.

This incident highlights multiple failures in the nursing home’s duty of care: failure to follow established care plan requirements, failure to implement supervision protocols despite known fall risks, and failure to provide necessary assistance during a high-risk activity (walking after meals) that had been specifically identified as requiring staff support. The severity of the resulting injuries – brain hemorrhages requiring ICU admission – underscores the critical importance of following safety protocols for vulnerable residents with cognitive impairment and mobility issues.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Rushville Nursing & Rehab Center when staff failed to use a required gait belt while helping a legally blind resident walk, resulting in a fall that caused multiple severe fractures and required surgery.

The resident in question had a history of muscle weakness and osteoporosis and required substantial assistance with most movements. The resident was also legally blind and was only capable of seeing shadows.

On the day of the incident the resident was being helped to walk when they “went to pivot and tried to sit too soon and fell to the floor.” The fall resulted in multiple severe fractures, including what hospital records described as a “comminuted, displaced distal, femoral shaft/metaphysis fracture.” The injuries were so severe that the resident had to be airlifted to another hospital for specialized treatment.

The hospital surgical report revealed the extent of the injuries, showing the resident required “open reduction, internal fixation, left supracondylar distal femur fracture with intracondylar extension; and intramedullary fixation of a right tibial shaft fracture.” After surgery, facility notes indicated the resident “experienced a decline in her ability to function.”

The Director of Rehabilitation emphasized that the resident required three things for safe walking: one staff member’s assistance, a front-wheeled walker, and a gait belt. They stated firmly that “Everyone should have a gait belt used unless they are independent.” Multiple staff members, including other Certified Nursing Assistants, confirmed these requirements. The resident themselves confirmed they were not wearing a gait belt when the fall occurred.

Facility policy stated, “Gait belts should be used by all staff when ambulating or transferring a resident with an unsteady gait.”

The facility took decisive action following the incident. The Administrator confirmed that the nursing assistant who failed to use the gait belt “was terminated for not following the facility Gait Belt Policy.”

This case highlights how failing to follow basic safety protocols can result in serious injury to vulnerable residents, particularly those with multiple risk factors such as visual impairment, muscle weakness, and osteoporosis.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.