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Resident Chokes to Death After Being Served Wrong Diet and Left Unsupervised at Fairhaven Christian Retirement Center

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The Illinois Department of Health has cited and fined Fairhaven Christian Retirement Center when staff served a resident with swallowing difficulties the wrong diet and failed to properly supervise her during mealtime, resulting in the resident choking and subsequently dying. Despite a recent order changing the resident’s diet to mechanical soft due to a previous choking incident, dietary staff served the resident regular pulled pork, which she impulsively consumed when briefly left unsupervised.

This case involves an elderly resident with multiple serious conditions including Alzheimer’s disease, vascular dementia, delusional disorder, and stroke syndrome. Just days before the fatal incident, the resident had experienced difficulty swallowing during lunch, “as evidenced by coughing/choking during the meal” when trying to eat “stringy meat.” In response to this earlier incident, hospice downgraded the resident’s diet to mechanical soft texture.

Despite this diet change, the facility failed to properly communicate and implement the new diet order. On the day of the fatal incident, a dietary aide “got confused” and served the resident pulled pork instead of ground meat. According to the Food Service Supervisor, “the resident was supposed to have ground meat and got pulled pork instead.” The Food Service Director explained that meat for mechanical soft diets “is supposed to be ground to make it safe so there are no chunks of meat,” noting her concern that with pulled pork, “what if they don’t pull it/shred it enough and there are still big pieces. That wouldn’t be safe.”

Compounding this error, staff failed to provide proper supervision for the resident, who was known to “eat fast” and be “very impulsive” with food. A certified nursing assistant (CNA) who was assisting the resident during the meal admitted that she “gave the resident a bite of food and heard another CNA tell one of her other residents to sit down so she went over to check on that resident.” During this momentary lack of supervision, the resident “grabbed food from her plate and put it in her mouth” and began choking.

Staff responded immediately when they noticed the resident choking. The nurse reported that the resident “could not talk; her face was turning blue.” Staff performed back blows, finger sweeps, the Heimlich maneuver, and suctioning, managing to extract “small pieces/chunks of meat,” but their efforts were unsuccessful. The resident was pronounced dead shortly after.

Several staff members confirmed that the resident was known to have problematic eating behaviors. One CNA stated the resident “has choked before; she would eat too fast and cough it up” and that “most of the time the resident would eat too fast so someone needed to be with her monitoring that.” The Director of Nursing acknowledged the resident “had a problem of eating fast; impulsive is the word she would use for her eating” and that she “needed supervision for meals for that purpose.”

However, these critical behaviors were not properly documented in the resident’s care plan. Although the care plan noted that she “eat[s] independently with supervision,” it “did not show that she is impulsive, grabs at food or will eat too fast if not monitored.” The MDS/Care Plan Coordinator admitted the resident “was known for hoarding, eating too fast, and being impulsive with eating” and that “this should have been on the resident’s care plan so staff could have been alerted to why the resident needed supervision at meals.”

The Medical Director confirmed that the resident’s diet had been downgraded specifically “to reduce the risk of aspiration and choking” and stated that “the resident choking on the food is most likely why she died.” He emphasized that “it is expected that staff follow diet orders.”

In response to this incident, the facility implemented several corrective actions, including a new diet card color system, increased verification of resident seating, improved communication of diet changes, and ensuring care plans specify the reasons residents need mealtime supervision. The facility also initiated a policy that “plates need to be cleared from the table when a resident that requires supervision/assistance is done eating and no longer has direct staff supervision.”

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.

Recent Amputee Fractures Remaining Leg After Being Left Unattended in Bed at Bella Terra Streamwood

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The Illinois Department of Health has cited and fined Bella Terra Streamwood when staff left an 84-year-old resident with dementia and a recent leg amputation unattended on a bed, resulting in a fall and femur fracture that required surgical repair. The facility failed to provide adequate supervision and implement appropriate fall prevention measures for a high-risk resident who had just returned from the hospital following an above-knee amputation.

This case involves an 84-year-old resident with multiple complex medical conditions including dementia, heart failure, severe morbid obesity, and a recent right above-knee amputation. The resident fell while being left unattended in her room, resulting in an “oblique fracture of left femur” that required surgical intervention.

According to hospital records, the resident “fell in facility” and “had pain in the left thigh last couple of days when admitted and x-rays to left femur demonstrate distal third femoral shaft fracture.” The surgeon noted that “she recently had an AKA (Above Knee Amputation) on the right side, so she needed her left side to transfer to wheelchairs therefore decision was made to undergo open reduction intramedullary nailing of the left femur.”

The facility’s Fall and Psychotropic Nurse, who conducted an internal investigation of the incident, stated that a Certified Nursing Assistant (CNA) had left the resident unattended on her bed. When asked if the CNA should have left the resident alone, the nurse acknowledged, “Yes, but she wasn’t left unattended very long.” The nurse further explained that the CNA “should have prepared the supplies prior to propping the resident up to clean her and not leave her unattended.”

When interviewed, the CNA provided conflicting information about the incident. Initially, she stated she was “reaching for a pad” at the doorway when she heard the resident scream, but later admitted, “My linen cart was in the hall outside the door, but you can say I left her unattended, but it was very fast.” The CNA also acknowledged she had limited knowledge about the resident, stating, “When I was working with her, I was not familiar with her at all, and no one told me whether she was a fall risk or not. No one told me anything about her at all.”

An agency nurse who was working that night confirmed that the resident was found “on the floor at the foot of the bed with her head under the footboard part.” The nurse also indicated she had not received proper information about the resident’s condition, stating, “I did not get any endorsement about [the resident] or that she came back with an amputated knee. I just knew she recently got back from the hospital, but I didn’t know for what.”

The resident’s roommate, who was determined to be cognitively intact, reported being “awakened around midnight when [the resident] was screaming loudly.” She confirmed seeing the CNA enter the room to take the resident’s gown off and then seeing the same CNA again when the resident started screaming.
The resident’s attending physician emphasized that the facility should have taken extra precautions due to the resident’s multiple risk factors, stating she “had dementia, severe morbid obesity, and was a recent leg amputee which made her more at risk and unstable (poor trunk control).”

A review of the resident’s fall prevention care plan revealed it had not been updated since nearly a year before the incident, despite her recent hospitalization and amputation. Only after the fall and fracture was her care plan updated to reflect her “recent hospitalization with surgical intervention, right AKA (Above Knee Amputation), recent fall with fracture to left femur.”

The facility’s fall prevention policy specifically states staff should “Pay close attention to residents at high risk for falls” and emphasizes the importance of anticipating residents’ needs and ensuring proper assistance with mobility. However, in this case, the facility failed to adequately communicate the resident’s high-risk status to staff, properly update her care plan following her amputation, and ensure appropriate supervision was maintained during care activities.

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.

Staff Fails to Assess and Treat Pressure Ulcer, Leading to Severe Wound Deterioration at St. Anthony Rehab & Nursing Center

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The Illinois Department of Health has cited and fined Saint Anthony Rehabilitation & Nursing Center when staff failed to complete a skin assessment upon a resident’s admission, delayed wound care treatment for a week, and did not update the care plan as a pressure ulcer severely deteriorated. The resident, who entered the facility with a documented history of pressure ulcers, eventually had to be hospitalized with multiple severe pressure wounds, including a massive Stage IV sacral pressure ulcer that required surgical debridement and ultimately led to discussions about hospice care.

This case involves a 75-year-old male resident with multiple medical conditions including diabetes, coronary artery disease, hypertension, paraplegia, and a history of pressure wounds. The resident was transferred from an out-of-state Veterans Administration hospital to a skilled nursing facility before being admitted to Saint Anthony Rehabilitation & Nursing Center.

Medical records from the previous skilled nursing facility documented that the resident had a “small sheared area under scrotum and coccyx with shearing and multiple small open areas.” A wound evaluation at that facility described a sacral pressure wound with a “history of Stage IV sacral pressure wound/full thickness” that was now “scattered areas with minimal depth.” The wound was measured at 6cm x 6cm x 0.1cm with “80% granulation tissue” and “20% intact normal color skin.” The treatment plan ordered “Zinc ointment to affected area twice daily and as needed.”

When the resident was transferred to Saint Anthony, facility staff failed to follow their own policy regarding skin assessments. According to the facility’s “Pressure Ulcers/Skin Integrity/Wound Management” policy, “A head to toe skin assessment will be conducted by a licensed nurse. It is recommended that this assessment is completed within the shift that the resident was admitted; however, it must be completed within 24 hours of admission.” The policy also states that “For new admission/readmissions, an immediate plan of care will be developed to address the immediate interventions to preserve and/or treat skin integrity issues.”
Despite these requirements, no admission skin assessment was completed when the resident was admitted. The Director of Nursing later confirmed this failure, acknowledging that the first skin assessment wasn’t completed until the resident was seen by a Wound Physician over a week after admission.

Furthermore, while the resident arrived with physician orders for wound care (“Cleanse sacral area with soap and water and apply Zinc twice daily and as needed”), these orders were not initiated at the facility until over a week after admission. Treatment records indicate the resident received no wound treatment during this critical period.

When the Wound Physician finally evaluated the resident, the sacral pressure wound had dramatically worsened. It was now described as a “full thickness Stage IV” wound measuring 9.0cm x 8.5cm with “thick adherent black necrotic tissue (eschar): 100%.” The wound progress was documented as “Exacerbated due to unknown since admission to facility.” The treatment plan was changed to “Leptospermum Honey once daily” covered with foam silicone border.

Over the next few months, the resident’s wound continued to deteriorate despite surgical debridements. A follow-up evaluation described the wound as measuring 12.4cm x 10.1cm x 0.2cm with “thick adherent black necrotic tissue (eschar): 100%” and noted that the wound had “Exacerbated due to infection.” The treatment plan was updated to include antibiotics and instructions to “Off-load wound; reposition per facility protocol.”

The resident was eventually sent to the emergency department for low urine output. Hospital records describe the resident’s condition in stark terms: “Patient has a large sacral pressure ulcer, foul-smelling (pictures in the chart).” The hospital performed an “excisional debridement of sacral wound in preparation for flap closure.” A palliative care note from the hospital described “Massive wounds. stage IV pressure ulcer located on his sacrum, stage III pressure ulcer located on his scrotum and a stage III pressure ulcer located on his right ischium.” Discussions with the family included options ranging from transfer to a tertiary care center for grafting to “comfort care hospice care limited care.”

Throughout this deterioration, the resident’s care plan was never properly updated. The care plan initially noted “Alteration in skin integrity – location coccyx. Identified on admission” with interventions including “Refer to Nurse Practitioner as appropriate,” “Dietary consult as indicated,” and “Turn and reposition routinely. Document any refusal.” Despite the significant changes in the resident’s condition, including wound deterioration, surgical debridements, and infection, the care plan was “never reviewed, revised or updated” and “did not include any pressure relief equipment, changes in treatments or subsequent wound infection.”

The Nurse Practitioner later stated she “did not actually visualize the resident’s wound” and “had no idea it was that big.” She noted the resident was “very non-compliant with care and resistive to weight shifting, offloading” and was “verbally aggressive, cussing staff out.” The Nurse Practitioner acknowledged that the resident’s care plan should have included documentation of his non-compliance with wound care interventions.

The Wound Physician who had seen the resident before admission to Saint Anthony stated the resident “did not have eschar on his sacral wound” at that time and acknowledged that “Zinc is not an appropriate treatment for a wound with eschar.” She expressed doubt that “not having Zinc for a week would lead to a wound covered in 100% Eschar” but stated “the order for Zinc twice daily should have been carried over though or re-evaluated upon admission.”

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.

Failure to Monitor Vital Signs Leads to Resident’s Hospitalization for Septic Shock at Aliya of Glenwood

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The Illinois Department of Health has cited and fined Aliya of Glenwood when nursing staff failed to regularly monitor vital signs, blood sugar levels, and follow treatment protocols for a resident with multiple chronic conditions who eventually developed respiratory distress and had to be hospitalized with septic shock and pneumonia. The facility’s staff missed critical warning signs, failed to properly document assessments, and did not administer needed medication despite the resident showing clear signs of deterioration over several days.

This case involves a 67-year-old male resident with multiple serious medical conditions including dysphagia following cerebral infarction, type 2 diabetes, hypertensive heart disease, systemic lupus erythematosus, and hepatitis C. The resident was on a specific care plan requiring monitoring of vital signs, blood sugar levels, and watching for signs of cardiovascular distress.

Despite clear signs of deterioration, facility staff failed to provide appropriate care in the days leading up to the resident’s hospitalization. Progress notes indicate that the resident was observed with “poor appetite for breakfast and lunch and diminished lung sounds with rumbling upon auscultation” at one point. The physician was notified and ordered a respiratory panel and chest x-ray. However, the laboratory reported that the sample was canceled due to being unlabeled.

Even more concerning, there was no documented follow-up to this canceled test. The medical record contained no assessments or vital signs for the resident for more than 24 hours following this incident. When a repeat test was finally performed, results showed the resident had tested positive for Respiratory Syncytial Virus (RSV).

A licensed practical nurse documented hearing “congestion during breathing in the resident” and contacted the primary doctor to alert them of symptoms. The doctor ordered cough medication, but the nurse did not document any assessment or vital signs after making this observation. When interviewed later, this nurse admitted, “Resident should have gone out the same day but she followed the order.”

Another registered nurse documented that the resident “refused to communicate with him when asked a question, he looks confused, refuses to take his medication and dinner.” The nurse recorded vital signs showing a blood pressure of 166/85 and oxygen saturation of 87%, which is dangerously low. The nurse documented that oxygen was administered and that they would “continue to monitor.” However, when interviewed, this nurse admitted, “I did not know that the resident have such medication [for high blood pressure], I don’t really know the resident because I hardly work that set.”

The medication administration record showed the resident was supposed to receive hydralazine as needed for elevated blood pressure (systolic over 160 or diastolic over 100), but staff only administered one dose despite documented high blood pressure. Additionally, blood glucose monitoring was ordered twice daily, but records showed no documented blood sugar checks for more than a week before the emergency.

The situation reached a crisis point when a night shift nurse documented the resident as “sweating, lethargic, not verbally responsive with labored breathing” with vital signs showing a blood pressure of 160/89. Emergency services were called, and the resident was transported to the hospital. Hospital records documented that the resident arrived “unresponsive and diaphoretic with shallow respirations” and was diagnosed with “septic shock and health care associated pneumonia.” The resident had to be intubated upon arrival at the hospital.

When interviewed, the Director of Nursing confirmed that “nurses are supposed to check blood sugar and vital signs as ordered and it should be documented.” The facility’s own job description for nurses states they are responsible for administering “prescribed medications and treatments according to policy and procedure,” recognizing “significant changes in the condition of residents and take necessary action,” and documenting “nursing care rendered, resident response, and all other pertinent and necessary data.”

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.

Resident Falls Out of Bed and Suffers Multiple Fractures When Staff Failed to Use Required Two-Person Assistance at Ascension Saint Joseph Village

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The Illinois Department of Health has cited and fined Ascension Saint Joseph Village when a Certified Nursing Assistant attempted to reposition a physically impaired resident on a specialized air mattress without obtaining required assistance from a second staff member, resulting in the resident falling from the bed and sustaining multiple serious fractures. The facility acknowledged in its own investigation that the fall could have been prevented if staff had followed established safety protocols requiring two-person assistance for residents on air mattresses.

This case involves a severely physically impaired resident who required substantial assistance with mobility. The resident’s care plan clearly specified she needed “assist of two people for all transfers,” and she was using a specialized low air loss mattress due to her physical condition. Despite these documented requirements, a CNA attempted to reposition the resident alone during nighttime care.

According to facility records, “Patient was receiving care by CNA, when she rolled to her right side. She stated she could not hold on and fell onto the floor.” The resident was found “laying partially face down with half her body on the bottom of the bedside table” with “an injury noted to the left lower leg, bruise to the right lower leg and pain to the left upper shoulder.” The resident was sent to the emergency room by ambulance, where hospital records confirmed she had suffered a “humerus shaft fracture, laceration of leg, pubic ramus fracture.”

When interviewed, the resident described the incident in detail, saying the CNA “was in a hurry” and that “it was an unnecessary accident.” She explained that she was on a low air loss mattress when “the girl was throwing me around. I fell on the floor hard… She was on my left side and she pulled the pad up to help me turn and I rolled off of the bed.
They usually use two people to turn me in bed. She was by herself.”

The CNA involved confirmed that she had grabbed the pad underneath the resident to help turn her onto her right side, but the resident “rolled off of the bed onto the floor” and “hit her left side on the bedside table.” The CNA claimed she had “taken care of [the resident] by herself many times before.” However, another CNA contradicted this, stating she had “never seen [the resident] require one person for assistance” and that the resident “has always been a maximum assist with two people, even before her fall out of bed.”

The Assistant Director of Nursing (ADON) confirmed that facility policy required two staff members when repositioning residents on low air loss mattresses, stating: “if a resident is on a low air loss mattress, then two staff should be repositioning the residents.” The ADON acknowledged that the resident’s fall “could have been prevented had there been two staff in [the resident’s] room” and confirmed the CNA “was not aware that if a resident is on a low air loss mattress, then two staff should be repositioning the residents.”

It’s important to recognize that chronic understaffing in nursing homes nationwide often places individual caregivers in difficult positions. Many nurses and nursing assistants are doing their best in challenging circumstances, frequently working short-staffed and caring for more residents than is optimal for safety. CNAs and nurses often work long hours with physically and emotionally demanding responsibilities, sometimes making split-second decisions while juggling multiple urgent resident needs. While safety protocols must be followed, systemic staffing issues in long-term care facilities can create environments where staff feel pressured to complete tasks quickly without adequate support.

The facility’s own investigation through their Safety Event Manager identified the primary factor leading to the incident as “One CNA providing care on an air mattress.” In response to the incident, the facility initiated corrective actions including reviewing and updating the resident’s care plan, monitoring other residents with air mattresses, and re-educating nursing staff on proper procedures for providing care to residents who use air mattresses.

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.

AU Well Care Home Failed To Both Protect Residents And Investigate Multiple Abuse Incidents Including Staff Biting Resident

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The Illinois Department of Health has cited and fined AU Well Care Home when staff failed to properly protect residents from multiple incidents of abuse, including staff-to-resident abuse and numerous resident-to-resident altercations. The facility administrator failed to thoroughly investigate abuse allegations, properly document incidents, report them to authorities within required timeframes, or implement effective protection plans for vulnerable residents with mental health diagnoses.

This case documents a disturbing pattern of abuse, violence, and neglect at a nursing facility specializing in psychiatric care. The investigation uncovered eight separate abuse incidents, including physical altercations between residents and staff-to-resident abuse, all of which lacked proper documentation, investigation, and follow-up as required by regulations.

One of the most serious incidents involved a physical altercation between a resident with bipolar disorder and a certified nursing assistant (CNA). According to the resident, after complaining about how staff had picked her up after a fall, the CNA “scratched her face, hit her in the eye, and bit her finger.” When examined by the surveyor, the resident had multiple injuries: several scabbed scratches around her left eye (measuring 1-inch, 1-inch, 1/2-inch, and 1.5-inch), a 2 cm scabbed scratch on her nose, a 2 cm scabbed scratch on the tip of her nose, a 2-inch scabbed scratch below her right eye, and a bruised/swollen right eye with yellow drainage. Her right pinky finger had a 1/2 inch laceration.

Hospital records confirmed the resident had been involved in an “altercation with staff member” and documented that she had been “scraped on her left cheek” and sustained a “human bite of finger” that required antibiotic treatment. The hospital report cautioned that “human bites are often more serious than animal bites” and “wounds are more likely to become infected because of the germs in a person’s mouth.”

Witness accounts contradicted the administrator’s initial claim that the CNA was merely defending herself. A nurse who was first on the scene stated, “I was the first one on the scene. [The resident] was holding onto [the CNA’s] hair and [the CNA] was holding on with hand to her hair and the other hand she was pushing on [the resident]. [The resident] has scratches on her face that were open and bleeding. The scratches were on her whole face.” This nurse specifically noted, “I did not see [the resident] holding any pillowcase,” contradicting the administrator’s claim that the resident had been swinging a pillowcase filled with soda cans.

The situation worsened when a licensed practical nurse (LPN) later threatened the same resident. A Regional MDS Consultant provided a written statement describing how he heard the LPN tell the resident he “wasn’t going to ‘allow her’ to ‘attack’ another female staff member and if she did, he was going to ‘beat her to death.'” Despite this threat occurring in the administrator’s office, no immediate action was taken to protect the resident. The Regional MDS Consultant reported that when he tried to intervene, the administrator told him to “keep my mouth shut about thing I don’t ‘know what I’m talking about.'” The LPN was allowed to continue working that night and was later permitted to resign rather than be terminated.

The investigation also documented multiple resident-to-resident incidents, none of which were properly investigated or documented. These included a resident punching another resident in the face, causing visible bruising; a resident hitting another resident who was screaming; a resident grabbing another resident’s arm to prevent being punched; and verbal abuse between residents that was witnessed by the surveyor. In one case, two residents who had been involved in a physical altercation were observed sitting unsupervised just five feet apart from each other in the dining room after the incident.

When asked for documentation of investigations, the Regional MDS Consultant candidly admitted, “I am not going to lie we have nothing.” The Regional Chief Executive Officer confirmed the facility had no written investigations for any of the incidents. The administrator was described as a “no call no show” during part of the investigation, and staff could not locate any documentation of the reported incidents.

The situation was particularly concerning given the facility’s specialization in psychiatric care, with many residents having diagnoses such as bipolar disorder, schizophrenia, depression, and anxiety. Despite these complex needs, there was no evidence that staff had received specialized training on caring for residents with mental illness.

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.

Resident Fractures Femur in Fall During Improper Transfer at Sharon Health Care Elms

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The Illinois Department of Health has cited and fined Sharon Health Care Elms when nursing staff twice attempted to manually transfer a resident with left-sided paralysis without using the required mechanical lift or proper assistance, resulting in the resident falling and suffering a distal femur fracture. The resident, who had a documented history of cerebral palsy and previous hip fracture, was supposed to have all transfers performed with a mechanical lift by two staff members according to the resident’s care plan.

The case involves a highly vulnerable resident with cerebral palsy, left-sided paralysis, and a history of falls including a previous hip fracture. The resident’s care plan clearly stipulated “Transfers: resident requires extensive assistance by two staff to move between surfaces using a mechanical lift.” This requirement was reinforced in the Minimum Data Set assessment, which stated the resident “requires extensive assistance of 2 staff members and mechanical lift for all transfers.”

Despite these clear directives, nursing staff attempted to manually transfer the resident without proper equipment or assistance on two separate occasions within a two-week period. The first incident occurred when a Certified Nursing Assistant (CNA) attempted to transfer the resident from wheelchair to shower chair without using the mechanical lift. According to the facility’s fall investigation report, the CNA “was behind the resident holding her while the resident held shower bar. The resident jerked around and fell on her buttocks.” When interviewed, the CNA claimed she “didn’t know she was supposed to transfer the resident at all times with a mechanical lift” and “hadn’t worked with the resident very often.”

Following this first incident, staff was supposedly educated on the resident’s transfer requirements. However, just over two weeks later, another CNA attempted to transfer the resident without the mechanical lift, resulting in a more serious fall and injury. The nursing progress notes documented: “CNA came to Nurses’ Desk and stated the resident needed something for pain.” When the nurse visited the resident, the resident complained of pain in her “left upper thigh” describing it as “deep aching.”

Later documentation revealed more details about this second incident. The nurse wrote that the CNA had “lowered the resident to the floor” and the resident was “complaining of pain in the left leg, describing it as excruciating” and was “unable to move her left leg.” However, the full truth only emerged gradually. Initially, the CNA claimed she “only lowered the resident to the floor” when the resident’s “leg buckled.” The nurse didn’t immediately consider this a fall or file a report. The Director of Nurses later clarified that “even when you lower someone to the floor, it’s considered a fall.”

The resident was eventually sent to the emergency room where hospital records documented a very different story from what staff initially reported. The hospital history states the resident “was reportedly being transferred by the staff when the resident was dropped, landing on her left side.” Imaging revealed “a distal periprosthetic femur fracture on the left.”

When interviewed during the investigation, the resident became “visibly upset, crying when talking of incident” and repeatedly stated “I hurt. I’m afraid of the lift.” The resident also specifically recalled “staff dropped me.” The second CNA admitted during interviews that she “wasn’t aware she was supposed to transfer the resident with a mechanical lift and additional staff assistance, at all times.”

The Care Plan Coordinator, who was responsible for all facility fall investigations, confirmed that both CNAs had attempted to transfer the resident without using the required mechanical lift or having a second staff member present for assistance. The coordinator explained that the resident “does not stand and has been a mechanical lift for the past two years” and that “facility policy is for all mechanical lift transfers to be performed with two staff members present.”

The physical and emotional consequences of these incidents were apparent during the investigation when two CNAs prepared to transfer the resident using the mechanical lift as required. The resident “began yelling out and was tearful with any movement of her left leg,” demonstrating the ongoing pain and fear resulting from the improper transfers.

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.

Resident Falls from Mechanical Lift During Improper Transfer at Piatt County Nursing Home

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The Illinois Department of Health has cited and fined Piatt County Nursing Home when staff members failed to follow proper safety protocols while using a mechanical lift to transfer a severely cognitively impaired resident, resulting in the resident falling to the floor and sustaining a fractured clavicle and a scalp laceration requiring staples. The resident, who was totally dependent on staff for transfers, experienced significant pain from these injuries and required emergency transportation to the hospital for evaluation and treatment.

The incident occurred when two Certified Nursing Assistants (CNAs) were transferring the resident from bed to wheelchair using a total body mechanical lift. According to facility records, the resident had multiple diagnoses including neuropathy, left knee pain, hyperlipidemia, arthritis, anxiety, and depression. The resident’s Minimum Data Set documented “severely impaired cognition” and being “totally dependent on staff for transfers.”

During the transfer, one CNA operated the lift while the other CNA adjusted the wheelchair. Neither CNA was providing hands-on support to the resident during the transfer, despite facility policy requiring this safety measure. As one CNA moved the lift away from the bed toward the wheelchair, the securing clip from the sling came undone, causing the resident to fall from the lift onto the floor.

A witness statement from one of the CNAs described hearing a “click” sound before the resident fell: “I was behind the total body mechanical lift, using the remote and lifted the resident from the bed while [the other CNA] was at the resident’s wheelchair, and I began moving the resident from over the bed to towards the wheelchair. I heard a click, the left clip of the sling near the left shoulder came undone, and the resident fell from the sling, landing on the floor.”

The facility incident report documented that the resident “fell onto the resident’s left side on the floor and was yelling in pain.” A nurse called to the scene found the resident “laying on the floor on his stomach, with bleeding noted from the left side of the resident’s head.” The resident “complained of pain to the left hand which he was laying on” and was “unable to give a description of the incident due to pain.”

The resident was transported by ambulance to the hospital emergency department where examinations revealed a “left clavicle (collarbone) fracture and scalp laceration requiring staples as a result of the fall.” Hospital records confirmed the resident “complained of pain while in the emergency department and received narcotic pain medication.”

The investigation revealed that the facility’s policy titled “Lift Machine, Using a Mechanical” clearly states that “at least two trained staff are needed to safely move a resident with a mechanical lift” and staff must “gently support the resident as she/he is moved.” Staff interviews confirmed they were aware of this policy, with multiple CNAs stating the resident’s transfer “is supposed to be completed by two staff members using the total body mechanical lift.”

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.

Neglect Leads to Severe Pressure Ulcers with Bone Exposure at Loft Rehab of Decatur

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The Illinois Department of Health has cited and fined Loft Rehab of Decatur when nursing staff failed to provide proper wound care and timely incontinence assistance to a cognitively intact resident, resulting in multiple severe pressure injuries including a Stage IV pressure ulcer with bone and muscle exposure. The facility also failed to notify physicians about the wounds, implement pressure-relieving interventions, or provide recommended treatments, causing preventable suffering and worsening of the resident’s condition.

The case involves a cognitively intact resident who was wheelchair dependent and frequently incontinent of both bowel and bladder. Despite facility policies requiring appropriate treatment for incontinence and prevention of pressure injuries, the resident developed multiple severe pressure wounds that were inadequately assessed, documented, and treated.

The resident was admitted to the facility with documented skin integrity issues, but the admission progress note indicated “skin is intact; old bruising from fall that caused hospital admission.” The resident’s Minimum Data Set assessment documented that they were “dependent for transfer and toileting, and requires substantial/maximal assistance of staff for rolling in bed” and “frequently incontinent of urine and bowel.”

About a month after admission, a nursing assistant discovered “an open area on right buttock” while providing evening care. The nurse documented cleansing the area and applying medical-grade honey, but there was no documentation that a physician or family was notified. No formal wound assessment was documented until three days later, when the wound measured 1.3 × 0.6 × 0.1 cm. Eventually this small wound had dramatically worsened, measuring 3.8 × 4.5 cm. Two weeks later, a Wound Nurse Practitioner documented it as a Stage IV pressure ulcer measuring 8.0 × 5.0 × 4.5 cm.

The resident also developed pressure injuries on both heels within three weeks of admission. These were initially documented as “blood blisters to both heels” measuring 1.2 × 1.5 cm on the left heel and 1.2 × 1.0 cm on the right heel. Despite orders for daily treatments, the facility’s Medication Administration Record showed multiple days where treatments were not documented as completed. Both heels had “leathery black eschar approximately 2.5 inches in diameter.”

The resident, who was cognitively intact, reported concerning issues with care, stating: “I put on my call light and very often the aides come in and turn off the call light and then don’t return to help me. I have bed sores and they don’t change my (adult diaper).” The resident described sitting for extended periods without incontinence care, saying “I (urinated) this morning in therapy and I have sat up in this chair since about 9:00AM without being changed.” The resident also reported a specific incident where they “had become incontinent of bowel while standing in therapy” and a nursing assistant “came to resident’s room and turned off the call light but did not clean resident.” The resident stated it was three hours before they received incontinence care.

These concerns were not isolated incidents. Facility Resident Council Meeting Minutes documented complaints of “call lights taking 30 minutes or longer to be answered” and that “staff often answer the call lights, turn the light off, say they will be back, but then never return to meet the resident’s need.”

When interviewed, the Wound Nurse Practitioner expressed significant concern, stating “I was very concerned the facility did not report the area on (resident’s) ischium until it was a Stage IV (pressure sore).” The Nurse Practitioner confirmed that the pressure ulcers were “avoidable” and that “if I had been aware of the wound on resident’s Ischium sooner I could have made recommendations and evaluated and treated before the wound became so extensive.”

The Wound Nurse Practitioner had recommended both pressure-relieving boots for the resident’s heel wounds and a special low air-loss mattress, but observations showed these interventions were not consistently implemented. A nursing assistant who regularly cared for the resident admitted being unaware of the need for pressure-relieving boots. The resident stated, “the doctor said I should have a special mattress, but I haven’t got one.”

By the time of the investigation, the situation had become critical. The surveyor observed that the “resident’s Ischium/Coccyx wound measured approximately four inches in diameter and three inches deep with malodorous yellow drainage. Muscle and bone were visible. Both heels had leathery black eschar approximately 2.5 inches in diameter.”

The situation was deemed so severe that the facility was cited for “Immediate Jeopardy”—the most serious level of violation.

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.

Failure To Assess Falls Leads to Suffering and a Delayed Hip Fracture Diagnosis at Jerseyville Nursing & Rehab Center

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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.

Resident Dies When Staff Fail to Perform CPR At Fair Oaks Rehab & Healthcare

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The Illinois Department of Health has cited and fined Fair Oaks Rehab & Healthcare when a nurse discovered a resident without vital signs and failed to initiate cardiopulmonary resuscitation (CPR), despite the resident being designated as “full code.” Emergency responders who arrived approximately 40 minutes after the resident was found unresponsive were the first to perform CPR, by which time it was too late to save the resident’s life.

The incident involved a female resident whose care plan clearly documented that she was a “FULL CODE” with instructions to “Ensure resident’s wishes are honored in regard to any advanced directive.” According to facility records, a Registered Nurse (RN) entered the resident’s room around 5:40 PM to check on her and found she had “no bp (blood pressure), no pulse, no respiration.” The nurse noted the resident was “cold to touch” with “mottling on left side of body.”

Rather than immediately initiating CPR as required for full-code residents, the nurse called for another nurse to verify the absence of vital signs, then contacted the Manager on Duty (MOD) to report the resident “had passed away.” When asked by the MOD if the resident was on hospice, the nurse replied, “No, she was a full code.” The MOD immediately instructed the nurse to “get off the phone and initiated compressions and have someone call 911,” but the nurse refused, stating, “No, she is already mottled and dead, I’m calling [the Director of Nursing].”

The Director of Nursing (DON) reported receiving a call from the nurse at 5:49 PM, during which the nurse informed her the resident “had passed away.” When the DON asked about the resident’s code status, the nurse had to check before confirming she was a full code. The DON stated she “told her that she should have started CPR right away, and needed to start a code.” When the DON called back to check if CPR had been initiated, the nurse admitted she had not started CPR, insisting, “She’s gone, it looks like she has been gone for a little while.”

Multiple staff members confirmed that no CPR was performed by facility staff at any point. A Certified Nursing Assistant (CNA) reported that after the nurse discovered the resident without vital signs, the nurse told her the resident “had passed away and she needed to clean her up.” The CNA proceeded to provide incontinence care to the resident while waiting for emergency services. Another nurse who had verified the absence of vital signs heard the first nurse say, “Oh my God, this patient is a full code,” followed by, “I am not doing CPR, I am calling 911.”

The local Fire Department was not called until 6:06 PM—approximately 26 minutes after the resident was found unresponsive—and arrived at the scene at 6:22 PM. According to the Deputy Chief, “the resident’s face was pale, lips were pink and her core and arms were still warm to touch,” suggesting the resident had not been deceased for long. Emergency responders immediately initiated CPR after confirming the resident was a full code. The Fire Department’s narrative specifically noted that “no one was performing CPR upon their arrival and that their CPR was the first CPR initiated.”

A Nurse Practitioner interviewed during the investigation expressed surprise at the resident’s death, stating she “had just seen the resident a few days prior and she was doing ok.” The Nurse Practitioner emphasized that mottling “does not always mean that they are deceased” and “can have mottling for various reasons including hypoxia, change in heart rhythm, or change in vitals.” She insisted that “a code is still warranted even if the resident has mottling present.”

Following this incident, the facility was cited for Immediate Jeopardy—the most serious level of violation.

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.

Resident Dies When Staff Fail to Perform CPR on Choking Resident At Bethany Rehab & Healthcare Center

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The Illinois Department of Health has cited and fined Bethany Rehab & Healthcare Center when staff failed to initiate cardiopulmonary resuscitation (CPR) on a full-code resident who stopped breathing after choking on food. The delay in resuscitation efforts continued until emergency responders arrived approximately eight minutes later, despite facility policy requiring immediate CPR for residents designated as “full code.”

The incident involved a female resident who had been identified as having difficulty swallowing related to facial pain from burn wounds. According to nursing notes, the resident had been “sleeping on and off” throughout the day and had eaten only “25% of her lunch.” During an evening family visit, a family member alerted a Licensed Practical Nurse (LPN) that the resident was choking. The nurse entered the room to find family members attempting to position the resident upright while food was visible “in and around her mouth.”

The nurse reported that he cleaned food from the resident’s mouth and heard “gurgling” sounds, which led him to believe she had aspirated food. He decided to call 911, leaving the room to make the call. While the nurse was calling 911, a family member approached him at approximately 5:35 PM, making a hand gesture across his neck and stating the resident had “stopped breathing.” Although the nurse claimed he “rushed for the crash cart,” he admitted he did not initiate CPR before paramedics arrived at 5:41 PM – approximately six minutes after being informed the resident had stopped breathing.

Multiple staff accounts confirmed that no CPR was performed prior to paramedics’ arrival. A Registered Nurse stated she was called by the LPN “to verify a resident’s death” before paramedics arrived and found the resident with “no heart rate, no respirations.” She assumed the resident was DNR (Do Not Resuscitate) because “V4 did not call a code or initiate CPR.” Another Certified Nursing Assistant confirmed that “CPR was not started until the paramedics arrived.”

The paramedic who responded to the call reported that when he arrived at the facility, he was initially told by the male nurse that the resident “had passed away.” Upon entering the resident’s room, he found no staff members present, only family, and “CPR was not being performed.” When he inquired about the resident’s code status and learned she was “full code,” he informed the family that CPR would need to be initiated. Despite the son’s objection, the paramedic explained that “according to protocol, CPR must be initiated because the resident was a full code, and none of the family members were her POA (Power of Attorney).” Paramedics finally began CPR at 5:43 PM – approximately eight minutes after staff were notified the resident had stopped breathing.

Both the facility’s on-call nurse and Medical Director confirmed that CPR should have been started immediately upon determining the resident had no pulse or respirations. The Medical Director emphasized, “You must start CPR immediately to achieve the best outcome. Ten minutes is way too long to wait and could definitely affect the outcome of a resident.” The paramedic similarly stated, “Six to ten minutes is a long time to wait to start CPR. There would be no blood return to the brain and brain death/cell death occurs.”

The facility’s own policy explicitly states that “the chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse.” Multiple facility records, including the Transfer/Discharge Report and Order Summary Report, confirmed the resident was designated as “Full Code,” meaning life-saving measures were required.

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.

Resident Strangled to Death After Head Becomes Wedged Between Bed Rail and Mattress At Axiom Healthcare Of Mount Vernon

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The Illinois Department of Health has cited and fined Axiom Healthcare Of Mount Vernon when a resident with dementia and Parkinson’s disease died from positional asphyxiation after his head became trapped between a bed rail and mattress. The facility failed to properly assess bed rail safety, obtain proper physician orders, or implement adequate monitoring for a resident with known history of trying to exit his bed.

The incident involved an 82-year-old male resident with multiple medical conditions including Parkinson’s disease, Type 2 diabetes, morbid obesity, dementia, and hydrocephalus. The resident was described as having severe cognitive impairment and was known to frequently attempt to exit his bed by “throwing his legs out.”

In the early morning hours, a Certified Nursing Assistant (CNA) found the resident in a compromised position with “his head lodged between the mattress and handrail” while his body was sitting on the floor. According to the coroner’s report, the cause of death was determined to be “positional asphyxiation” with the death certificate specifically noting the resident was “found in a seated position on floor beside bed” with “legs straight out and head and neck between mattress and bed rail.”

Investigation revealed numerous failures in the facility’s bed rail assessment and safety protocols. Though the facility had obtained a consent form for half side rails on the day of admission, they failed to complete proper assessments, obtain physician orders, or document the rails in the resident’s care plan. The facility’s own bed rail evaluation forms were incomplete, with the bottom sections where the Interdisciplinary Team makes determinations about bed rails left blank with “no staff signatures, initials or dates.”

Even more concerning, the evaluation incorrectly answered “Y” or yes to two critical questions: “Does the bar prevent resident from exiting bed? (Yes = Restraint)” and “Does the bar interfere with the resident’s access to their own body? (Yes = Restraint),” indicating staff knew the rails were being used as restraints rather than for mobility assistance.

Multiple staff interviews exposed systemic failures in the facility’s bed rail program. The Director of Nursing stated she “wasn’t familiar with Side Rail Assessments” and “was not sure who does them.”
The Maintenance Director admitted he “did not know anything about” checking the gap between the side rail and mattress, had not been routinely inspecting installed bed rails, and discovered an unused inspection log book that “has not been kept up or has not been done for a long time, the last one done was in 2023.”

The Administrator revealed a concerning process for bed rail installation, stating “sometimes the family wants them on so we put them on, and sometimes physical therapy may recommend.” The resident’s family member/Power of Attorney stated she “[doesn’t] ever remember signing a consent for side rails” and “just doesn’t understand why they had the side rails on except to keep him in the bed.”

Physical examination of the bed involved in the incident revealed significant safety hazards. The bed had “an air loss mattress on it with metal 1/2 side rail in place and gaps were observed between the mattress and the side rails.” When measured, the gap was approximately 4 1/4 inches, expanding to 5 inches when someone sat on the mattress. When the surveyor grabbed the rail, “it was loose and moved outward” creating a 7 1/8-inch gap—more than enough space for entrapment to occur. One nurse described the rails as “the old brown metal ones that mount on the bed and were very big” with “at least a 6-inch gap” between the rail and mattress. Another staff member acknowledged that the “side rails were too big, they were just too big for the bed.”

The resident’s death appears to have occurred during an attempt to exit his bed—something staff knew he frequently tried to do. The CNA who found him noted “the resident was really wet, and he was poopy too,” suggesting he may have been trying to get up to use the bathroom. Despite his known history of exit attempts and a recent fall assessment documenting “attempting to sit on side of bed independently,” the facility failed to implement adequate monitoring or safety measures. Staff admitted they had not checked on him between 10:00 PM and 1:00 AM, and while the resident had been ordered to have a “pin alarm to person while awake,” this alarm was not in use while he was in bed.

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.

Arc At Hickory Point Resident’s Femur Fractured During Improper Mechanical Lift Transfer

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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.

Resident Nearly Suffocates Due To Lack Of Critical Breathing Tube Equipment At Aperion Care Elgin

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The Illinois Department of Health has cited and fined Aperion Care Elgin when they failed to maintain proper emergency tracheostomy supplies for a resident with a tracheostomy tube, resulting in delayed care during a respiratory emergency. The resident suffered from acute respiratory distress and had to be transferred to the hospital for treatment of acute respiratory failure after facility staff could not properly address a tracheostomy tube obstruction.

The resident in question was admitted to the facility with multiple medical conditions including a subarachnoid hemorrhage from an intracranial artery, ruptured aneurysm, acute respiratory failure with hypoxia, and had a tracheostomy (an artificial opening in the neck with a tube inserted to help with breathing). The resident was receiving supplemental oxygen at 6 liters via a trach collar.

This incident was not the first time the resident experienced problems with his tracheostomy. Less than a week before the emergency, the resident’s entire tracheostomy tube had become dislodged. A Licensed Practical Nurse (LPN) attempted to reinsert it but was unsuccessful, resulting in the resident being transferred to the hospital. The resident returned the same day with a new, smaller tracheostomy tube (changed from a size 6 to a size 4).

On the night of the emergency, the resident began experiencing low oxygen levels. The nurse administered a nebulizer treatment and then attempted to suction the tracheostomy but encountered resistance. When the nurse tried to change the inner cannula (the removable part inside the main tracheostomy tube), she also met resistance. According to the nurse, “I was not trained in changing entire tracheostomy tubes,” so she contacted the resident’s physician who ordered transfer to the hospital.

When emergency paramedics arrived, they found the resident’s oxygen levels were worsening. They attempted to ventilate and suction but also encountered resistance. The paramedic explained, “The protocol for when resistance is met with patients with tracheostomies is to change the entire trach tube.” When the paramedic asked the nurse if she had attempted to change the tube, she responded that she “was not trained to change entire trach tubes.”

The nurse provided the paramedic with a tracheostomy kit, but it contained the wrong equipment—an uncuffed tracheostomy tube without an obturator (a guide used to help insert the tube safely). Despite having inadequate equipment, the paramedics managed to change the tracheostomy tube and ventilate the resident before transferring him to the hospital.

At the hospital, the resident was admitted for “acute on chronic hypoxic respiratory failure.” Hospital notes indicated “EMS attempted to change the inner cannula, but they did not have the proper equipment; however after the clogged inner cannula was removed his SpO2 improved.” The hospital report continued: “Upon arrival to the ED he presented with stable and appropriate vitals but he quickly became hypotensive and hypoxic. His trach was connected to mechanical ventilation.”

An inspection of the resident’s bedside supplies revealed serious deficiencies. A box of size 6 inner disposable cannulas at the bedside had expired nearly a year earlier. The nurse acknowledged that “tracheostomy equipment should be checked and disposed of when expired.” More concerning, there were no emergency tracheostomy exchange kits for the resident. The nurse confirmed that residents with tracheostomies required emergency exchange tube kits with an obturator “for emergency situations at the bedside.”

The Respiratory Therapist Manager, who provided consulting services to the facility, confirmed that residents with tracheostomies required specific emergency equipment at bedside, including “trach tube kits with the same type of trach tube and an obturator.” She specified the kits should include “one of the same size and a downsized one” and that equipment “should be checked routinely to ensure safe trach care is being provided.” She also noted that licensed nurses could change tracheostomy tubes “if there was a doctor’s order and if they were trained appropriately.”

The Director of Nursing confirmed that when the resident returned from his previous hospital visit, his tracheostomy tube had been replaced with a smaller size 4 tube. She stated the facility expects nursing staff to ensure residents with tracheostomies have the required emergency supplies at bedside, including kits with a tube of the same size, a downsized tube, and an obturator. Importantly, she stated she “expects nurses to be able to change entire trach tubes monthly as ordered and during emergencies.”

The resident’s care plan specifically included “TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside.” Furthermore, the resident’s orders clearly stated “Trach: Licensed nurse may re-insert trach tube, as needed for dislodgment” and “Trach: Change Trach tube every day shift every 1 month(s).”

The facility’s Admission Data Form for tracheostomy patients specified that equipment needed included “one same size trach and one downsized trach at the bedside at all times.” However, the facility’s Tracheostomy Care policy contradicted this by stating: “Emergency Care: If outer tube comes out, stay with resident and summon assistance. A rubber tipped hemostat maybe used to maintain opening. If necessary, suction the resident through the opening. Physician generally responsible for reinserting new tube.”

This conflicting policy may have contributed to the nurse’s belief that she was not authorized to change the tracheostomy tube, despite having physician’s orders permitting her to do so. The policy also did not provide instructions on how to perform the procedure, suggesting inadequate training for staff on this critical emergency procedure.

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.

Resident Suffers Serious Burn When Foot Gets Trapped Under Room Radiator At Alden Park Strathmoor

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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.

Staff Leaves High-Fall-Risk Resident Alone on Toilet, Resulting in Hip Fracture at Villa Health Care East

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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.

Dark Day At Sunny Acres When Staff Fails to Treat Resident’s Urinary Catheter Problems Resulting in Life-Threatening Infection

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The Illinois Department of Health has cited and fined Sunny Acres Nursing Home when nursing staff repeatedly failed to properly monitor, document, or seek treatment for a resident with urinary catheter problems showing clear signs of infection. The resident ultimately had to be hospitalized for intravenous antibiotics to treat a serious urinary tract infection and encephalopathy, a potentially life-threatening brain condition.

The resident in question had an indwelling urinary catheter, which is a tube inserted into the bladder to drain urine. Nursing notes initially documented that the resident’s urine was “dark and slimy with a foul odor,” and the Medical Director ordered a urinalysis. The urinalysis results came back positive for a urinary tract infection (UTI) caused by ESBL and E. coli bacteria, which are particularly concerning infections because they can be resistant to many antibiotics.

After this positive test result, nursing staff failed to document any physician notification or follow-up care plan. More concerning, the facility’s records showed the resident had no urine output for multiple shifts over several days. On one day, both overnight and day shifts documented zero urine output. On another day, third shift and day shift documented the resident’s urine output as zero, with no documentation for the evening shift.

A Certified Nursing Assistant (CNA) reported coming to work and noticing “the resident had no urine in her indwelling catheter bag.” The CNA properly reported this to a Registered Nurse, along with concerning observations that the resident “was throwing up in dining room and was more confused.” The CNA also noticed “brown urine in the resident’s depend [adult diaper], but not in the resident’s indwelling catheter bag.”

The nurse attempted to irrigate (flush) the catheter but was unsuccessful. Nursing notes later documented, “Resident complains of pain at the indwelling urinary catheter site, brown mucus discharge coming from vagina. Resident hasn’t voided in two days per CNA and documentation.” Only at this point was the Medical Director notified, who ordered the catheter removed and the resident sent to the emergency room.

At the emergency room, hospital staff placed a new catheter, which drained “dark gold urine.” The emergency room physician documented that the resident’s condition “could potentially be life threatening or risk to bodily function.” The resident was diagnosed with a UTI due to urinary retention, with evidence of cystitis (bladder inflammation) and hydronephrosis (kidney swelling due to urine backup).

After returning to the facility with antibiotics, the pattern of poor monitoring continued. Records showed multiple shifts with either no documentation of urine output or documented concerning low outputs (as little as 15 milliliters in an entire shift). Despite these red flags, there was no documentation of physician notification until several days later.

When the physician was finally notified of continued issues, she ordered another urinalysis. However, even after receiving this order, the nursing staff failed to collect the specimen promptly. One nurse admitted she “didn’t have time” to collect the sample and passed the task to the next shift. Another nurse collected the sample but left it in the refrigerator. The urinalysis wasn’t actually performed until several days after it was ordered.

When finally collected, the resident’s urine was described as “green, thick, and has a foul odor,” at which point the resident was sent back to the hospital. Hospital records show the resident was admitted for intravenous antibiotics to treat both the UTI and encephalopathy, a brain condition that can be caused by infection and may be life-threatening if left untreated.

Even after this second hospitalization, the pattern of poor monitoring continued, with more documented instances of low or absent urine output without proper physician notification.
The Medical Director stated she “would expect the facility to call and notify if a resident with a catheter has not voided in an eight-hour shift.” She confirmed that neither her office nor her personal cell phone received any calls about the missing antibiotic orders or the resident’s lack of urination. She emphasized that the resident “could have become very sick because of the facility not notifying of absent or low urine output” and could have developed sepsis, a life-threatening complication of infection.

The Director of Nursing admitted multiple documentation failures, stating “I tell the staff all the time to document it, or it didn’t happen.” When questioned about the delayed urinalysis collection, she stated that it “should have been collected the same day it was ordered” and admitted she “was not aware the resident’s medical chart had days with absent or decreased urinary output.”

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.

Resident’s Medical Emergency Ignored for Hours Despite Clear Signs of Distress at Stearns Nursing & Rehab Center

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The Illinois Department of Health has cited and fined Stearns Nursing & Rehab Center when staff failed to properly assess, monitor, and respond to a resident’s significant medical decline over several days, culminating in the resident being found unresponsive with foam coming from their mouth and nose. The resident suffered cardiac arrest during emergency transport to the hospital, required CPR, and was placed on a ventilator.

The resident in question was documented as cognitively intact, requiring some assistance with daily activities, and had advance directives indicating full code status with a request for all life-sustaining measures. The resident’s care plan confirmed they were “a full code and requests life sustaining measures.”

For approximately 3-4 days prior to the emergency, multiple Certified Nursing Assistants (CNAs) observed significant changes in the resident’s condition and behavior. One CNA stated, “the changes in [the resident] started [several days earlier] and this is when he started notifying the nurses and the Director of Nursing.” Staff consistently reported that these changes were markedly different from the resident’s usual behaviors.

On the morning of the incident, a speech therapist visited the resident around 9:00 AM and found them unresponsive in bed, lying flat with food nearby. The therapist stated, “she called out to [the resident] and no response” and “she performed a sternal rub and [the resident] did not respond.” When the therapist notified a nurse, she “was informed that this was a behavior and not to worry about it.” The therapist provided education to staff about not feeding the resident while lying flat.

The morning nurse recognized the seriousness of the situation and contacted the Nurse Practitioner between 10:30 AM and 12:00 PM, receiving orders to send the resident to the emergency room. However, rather than calling 911 for an immediate emergency response, the nurse called for a regular ambulance transport. When told there would be an hour wait for an ambulance, the nurse informed the oncoming shift nurse and left at the end of his shift.

When staff finally responded to the emergency around 4:30 PM, they found the resident with “respiratory depression. Pulse present, weak and thready… Resident diaphoretic, bilateral pupil dilation, increased oral/nasal secretions. White in color with thick frothy consistency. Resident unresponsive to verbal stimuli, tactile stimuli notes no response.”
During ambulance transport, the resident went into cardiac arrest, requiring CPR. At the hospital, the resident was diagnosed with “Cardiac Arrest and Severe Septic Shock” and required intubation and ventilator support.

In a Root Cause Analysis conducted by the facility, they admitted: “Facility failed to Assess, monitor, and provide timely treatment. Nurse failed to follow up, assess resident and call MD. Nurse thought this was resident behavior. Poor assessment skills by nurse.”

Both the Nurse Practitioner and the resident’s physician stated they were not properly informed of the resident’s deteriorating condition. The physician stated that “if he was notified that [the resident] was unresponsive to a sternal rub and attempts to arouse [the resident] had failed he would consider that an emergency and would have sent [the resident] to the hospital with lights and sirens.”

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.

Plymouth Place Neglects To Treat and Report Resident’s Toe Wounds Leading To Gangrene And Leg Amputation

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The Illinois Department of Health has cited and fined Plymouth Place when staff failed to properly assess, document, and report a resident’s worsening toe wounds for over three months, resulting in gangrene that required a full above-knee amputation of the resident’s left leg just one day after being transferred to another facility.

The resident in question suffered from multiple serious health conditions, including congestive heart failure, chronic obstructive pulmonary disease (COPD), respiratory failure, difficulty walking, and depression. Though cognitively intact, he required substantial assistance with most daily activities including toilet hygiene, showering, dressing, personal hygiene, and bed mobility. He was completely dependent on staff for transfers between surfaces, had an indwelling urinary catheter, and was always incontinent of stool.

From the day after his admission, the facility documented that the resident had wounds on his left toes. His care plan noted “Site: LT (Left) great toe scab. LT 2nd toe scab” and included interventions to “Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD.”

The facility’s Wound Care Nurse, a Licensed Practical Nurse (LPN), assessed the resident’s left toe wounds regularly for over three months. However, her documentation had serious deficiencies. She consistently referred to wounds on the “left toes” without differentiating which specific toes were affected. She recorded the same exact measurements—1 centimeter by 1 centimeter—for every assessment over the entire three-month period, rather than measuring each affected toe separately. There was no evidence she ever notified the resident’s physician about these wounds.

Most concerning, the Wound Care Nurse documented that the wounds, which she initially described as improving, had “stalled” in their healing about a month before the resident’s discharge. Despite this change in status, she still did not notify the resident’s physician. The facility Administrator later acknowledged that the nurse “should have documented separate wound measurements for each toe, as well as the appearance of each wound separately. There is no documentation to show she spoke to the Attending Physician, or that he was aware of the wounds.”

The resident’s attending physician saw him multiple times during this period for “wound care follow for superficial wounds” and “wound care as needed,” but his notes never specifically mentioned the left toe wounds. The physician later stated, “I depend on wound nurses and facility staff to do their job… If that changed, they should have notified me.”

After about three months at the facility, the resident was transferred to a different nursing facility. The Discharge Summary noted “Skin Intact: No,” indicating he still had skin issues, but no wound assessment was completed as required by the facility’s own form. The nurse who handled the discharge admitted, “I did not see the resident’s feet the day of his discharge from the facility. He wore shoes. He always wanted them on.”

A Certified Nursing Assistant who cared for the resident on his last day at the facility provided concerning information: “A couple of days before, his toe looked black on his big toe. The last couple of days it was dark. I reported it to the nurse, but she said it was already reported.” The assistant added that the resident “liked to keep his socks on because he said his feet were always cold, so we left his socks on.”

Most disturbingly, the Wound Care Nurse admitted to falsifying documentation, stating: “I did not actually see the resident’s toes on the day of his discharge. I did not do wound care on him the day he left even though I signed that I did it. I documented that I did his wound treatments, but I actually did not do the wound care treatments that day. He was gone from the facility by the time I got to him.”

Just one day after being transferred to the new facility, the resident was rushed to the hospital. A Vascular Surgery Nurse Practitioner documented that the resident “presents with ischemic left toes… gangrene left toes (1st through 3rd, starting to spread to 4th/5th).” The Nurse Practitioner noted they were “unsure of how long have been like that” but that the “family noted foul smell for over a week.”

A hospital podiatrist evaluated the resident and determined: “Given the amount of tissue loss and necrosis, a midfoot or proximal foot amputation is unlikely to heal and to be functional.” The resident and his family agreed to a more extensive amputation. Two days after admission to the hospital, the resident underwent a left above-the-knee amputation of his entire leg. Following surgery, his condition deteriorated, and he was admitted to the intensive care unit.

The resident’s physician later stated, “It is unlikely that someone would go from a one centimeter wound to full gangrene in a day. It is unlikely that gangrene would come in one day, especially with an odor.” He placed blame on the facility staff, saying, “These failures resulted in the poor outcome for the resident, requiring a leg amputation. That is not appropriate support or care for someone who comes to a facility.”

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.

Failure to Maintain Working Fall Alarms Leads to Resident’s Hip Fracture & Subsequent Death At Nature Trail Health & Rehab

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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.

Failure to Perform Skin Checks Leads to Severe Infected Pressure Ulcers At Generations At Applewood

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The Illinois Department of Health has cited and fined Generations At Applewood when staff failed to perform required weekly skin assessments on a dependent resident who developed multiple severe pressure ulcers while in their care, ultimately resulting in a stage 4 sacral wound with necrotic tissue that became infected and required hospitalization and six weeks of intravenous antibiotics.

The resident in question was admitted with multiple medical conditions, including local skin infection, difficulty swallowing, peripheral vascular disease, hypothyroidism, gastroesophageal reflux disease, and chronic kidney disease. According to facility records, the resident developed three pressure ulcers (also known as bedsores) after her admission – a stage 3 ulcer on her right elbow, a stage 4 ulcer on her left leg, and a stage 4 ulcer on her sacrum (lower back).

The sacral wound was particularly severe. A wound assessment note described it as a “stage 4 pressure wound” that was “full thickness” with a size of “8.0 x 15.5” centimeters. The depth was noted as “unmeasurable due to presence of nonviable tissue and necrosis.” In other words, the wound was so deep and filled with dead tissue that its true depth couldn’t be determined.

The resident’s condition deteriorated to the point where she needed hospitalization. Hospital records indicated she was admitted from the nursing home with “pressure ulcer on the right elbow and worsening of sacral decubitus ulcer with foul smell draining pus.” The infection was serious enough that she required intravenous antibiotics (Vancomycin and Zosyn), a surgical consultation, and planning for surgical debridement (removal of dead tissue). The hospital determined she would need “more than 2 medically necessary midnights of in-hospital care because of sacral decubitus ulcer infection” and planned for her to continue antibiotics for a total of six weeks after returning to the nursing home.

Assessment records showed that the resident had mild cognitive impairment and was completely dependent on staff for all activities of daily living. She was also always incontinent of both bowel and bladder, putting her at high risk for skin breakdown if not kept clean and dry.

Despite having an order for weekly skin checks since her admission, there was no documentation of any skin checks in her medical record. The wound care nurse later admitted that “the wound team was just treating resident’s leg wound that was present on admission and were not aware of anything going on in resident’s sacrum” until several months after admission. She acknowledged that “the wound care team did not do another skin assessment apart from the one done upon admission” and that “the facility dropped the ball this time, there was a gap in communication, resident’s wound could have been identified earlier.”

During an inspection visit, the resident was observed lying in bed and stated that she had not been changed yet that day, having been last changed the previous day, and felt that she was wet. She also mentioned that no one had changed her wound dressing yet, and she didn’t know who her assigned nursing assistant was for the day.

Later that morning, a nursing assistant and restorative aide were observed leaving the resident’s room with dirty linens. When asked to show the resident’s soiled incontinence brief, inspectors noted “a large area of reddish stain that saturated the brief.” The nursing assistant claimed the resident “was not wet, the stain is from her wounds.” When the resident’s wounds were examined, inspectors saw “a large area of deep wound on resident’s sacrum that looks red, with lots of drainage.”

Disturbingly, staff applied a clean incontinence brief on the resident with no dressing covering the wound, promising to inform the wound care nurse that the resident’s wound didn’t have any cover. Several hours later, the resident was observed still lying on her back and stated that no one had come to turn her or put a dressing on her wound.

When wound care was finally observed by inspectors, the Director of Nursing and a Wound Technician removed the resident’s incontinence brief and found it “soaked with wound drainage and there was no dressing covering resident’s wounds.” The Director of Nursing admitted “she was not aware that the resident did not have any dressing to her wounds, no one informed her.” She acknowledged that “the wound should not be left without dressing because it will be losing hemostasis” – meaning the wound would continue to drain and potentially bleed without a proper dressing.

The facility’s own policies required that residents “will be assessed to determine their risk factor(s) for pressure injury development, upon admission; weekly x 4 weeks following admission/readmission and at least quarterly thereafter” and that residents would “have their skin checked and documented utilizing the Treatment Administration Record… at a minimum of weekly.” These policies were clearly not followed in this case, leading to the development and worsening of severe pressure ulcers that ultimately required 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.

Two-Month Delay In Treating Diabetic Resident’s Toe Wound Leads To Leg Amputation At Breese Nursing Home

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The Illinois Department of Health has cited and fined Breese Nursing Home when staff failed to properly assess, document, and treat a diabetic resident’s toe wound for nearly two months, resulting in bone infection that ultimately required an above-knee amputation.

The resident in question suffered from several serious health conditions—diabetes, chronic lung disease, and morbid obesity. She also received dialysis regularly due to kidney failure. Despite these challenges, the resident’s mind remained sharp and clear.

The resident’s health conditions put her at high risk for skin problems, especially pressure ulcers—wounds that form when pressure on the skin reduces blood flow to an area. Because of this risk, the nursing home had orders in place to check her skin twice weekly, during her scheduled shower days on Tuesdays and Fridays.
Summer had arrived, and the resident was going about her usual routine—dialysis treatments three times a week, meals in the dining room, and watching her favorite TV shows in between. But beneath the surface, a silent problem was developing.

One day at her dialysis appointment, the resident spoke up. “My feet hurt,” she told the dialysis nurse. The nurse took a closer look and was alarmed by what she found—a large darkened area on the resident’s left heel and a concerning red-purple area on her right great toe and the top of her right foot. The dialysis team immediately notified the nursing home about these worrisome findings.

Back at the nursing home, a nursing assistant had also noticed these changes while helping the resident shower. The assistant documented “bruising” on the resident’s right foot and a “soft spot” on her left heel, then had a nurse sign the shower sheet to acknowledge these findings. The nursing assistant later recalled that what she had documented as “bruising” was actually “two darkened areas” on the foot.

Here’s where the story takes a troubling turn. Though these skin problems were documented by the nursing assistant and reported by the dialysis center, proper treatment for both wounds didn’t begin right away. The nursing home staff promptly started treatment for the left heel—cleaning it with saline, applying betadine, and leaving it open to air—but the right toe wound was largely overlooked.

The Assistant Director of Nursing later admitted that she “was so focused on treating the resident’s left heel” that she “wasn’t aware of the area of concern on her right foot,” despite documentation showing that staff had reported it to her. Other staff members painted a picture of communication breakdowns.

Nearly two months after the initial discovery, the Certified Wound Nurse Practitioner finally examined the resident’s right foot. What she found was alarming—the resident’s second toe was ischemic, meaning it wasn’t getting enough blood flow. The tissue was dying. The wound had progressed to a dangerous state, with “abundance of purulent drainage and pain at the site.” The resident was immediately sent to the local hospital for emergency treatment.

At the hospital, the resident told doctors the wound had been present for about a month but had been getting worse and more painful. Medical imaging revealed osteomyelitis—a serious bone infection—affecting multiple toes. The infection had progressed so far that surgeons had to amputate her right second toe.

But the story doesn’t end there. Just six weeks later, the resident was back in the hospital. Her foot wound had worsened despite the toe amputation, and the infection had spread. This time, doctors determined that the only way to stop the spreading infection was to amputate her right leg above the knee—a life-altering surgery that might have been prevented with proper early intervention.

When investigators interviewed the resident after all these events, she was lying in bed with her right leg amputated above the knee and her remaining left foot in a protective boot. She told them her feet still hurt all the time, rating her pain as a 6 out of 10 in her right residual limb and 8 out of 10 in her left foot. The investigators observed that her remaining left foot showed signs of poor circulation, with darkened skin between all toes and a scabbed-over dark heel.

The nursing home’s own policy stated they were “committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries.” The policy clearly defined responsibilities: licensed nurses were to “conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury” with findings “documented in the medical record.”

The Wound Nurse Practitioner put it bluntly: “Untreated wounds have the potential for serious harm or death due to infection.” The resident’s primary care nurse practitioner expected nursing staff to notify her or the physician the same day a new skin concern was identified, stating, “Staff should be assessing the resident’s feet because she has diabetes and anything on the foot with diabetes can continue to progress into a wound.”

In the aftermath of this tragedy, the nursing home implemented numerous corrective actions—conducting skin assessments on all residents, reviewing medical records to ensure weekly assessments were completed, revising policies, and educating staff. But for the resident who lost her leg, these changes came too late.

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.

Safety Belt Missing, Truth Stretched: How a Simple Transfer Led to Serious Injury At Bethany Rehab & HCC

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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.

Alden Lakeland’s Failure to Administer Critical Antibiotics Leads to Resident’s Life-Threatening Sepsis

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The Illinois Department of Health has cited and fined Alden Lakeland Rehab & Health Care Center when staff failed to administer two out of three prescribed antibiotics to a resident returning from hospitalization, resulting in the resident developing life-threatening sepsis that required emergency rehospitalization.

The resident in question was returning from a hospital stay. The hospital’s discharge instructions were clear: the resident needed to continue taking three powerful antibiotics – vancomycin, metronidazole, and cefepime – for six more days to fight a serious infection.

When the resident arrived back at the nursing home, an agency nurse was responsible for reviewing the discharge papers and setting up the medication orders in the facility’s system. The nurse later claimed to have properly transcribed all the orders and even spoke with a nurse practitioner to confirm them. “I transcribed the orders and called the nurse practitioner, and no orders were changed from the discharge paperwork,” the agency nurse insisted.

But something went terribly wrong. Despite the clear instructions, only one of the three antibiotics – cefepime – was ever administered to the resident. The other two medications, crucial for fighting the resident’s infection, were neither ordered from the pharmacy nor given to the resident.

The nursing home had a system designed to catch such errors. After an admission nurse enters medication orders, a quality assurance nurse is supposed to double-check everything. The Clinical Support Nurse who was responsible for this review later admitted her mistake: “I did not catch the medication errors. I must have missed it.”

For three days, the resident received inadequate antibiotic treatment. The Consultant Pharmacist who reviewed the case explained the serious nature of this error: “Cefepime would not have had enough coverage to effectively treat all of what grew in the resident’s cultures.” In simple terms, the single antibiotic being given wasn’t strong enough to fight all the bacteria causing the infection.

The resident’s condition deteriorated rapidly. In the middle of the night, a nurse observed alarming vital signs: a temperature of 100.4°F, racing heart rate of 135 beats per minute, elevated breathing rate, dangerously low blood pressure of 87/55, and oxygen levels that had plummeted to just 55%.

The telehealth physician who evaluated the resident recognized the seriousness of the situation immediately. The doctor diagnosed sepsis – a life-threatening condition where infection overwhelms the body – and ordered the resident to be transferred to the emergency department due to “hypotension and sepsis.”

When questioned about the incident, the facility’s physician reviewed the resident’s vital signs and confirmed, “The resident met sepsis criteria.” The doctor further acknowledged that the missing antibiotics “certainly could have contributed to the resident developing sepsis. I mean, the resident clearly needed the medication.”

The telehealth physician who had ordered the emergency transfer was even more direct about the seriousness of the situation: “Sepsis and septic shock is life-threatening.”
Remarkably, when the Administrator of the facility was asked about the definition of neglect, they replied, “I would have to google it to give you the definition, I don’t want to give you something wrong.” The Administrator also downplayed the severity of the resident’s condition, stating, “I wouldn’t say sepsis is a life-threatening condition but that would be more of a question for a clinician.”

This statement directly contradicted not only medical facts but also the facility’s own abuse policy, which defines neglect as “the failure of the facility, its employees or service providers to provide goods and services needed to avoid physical harm, pain, mental anguish or emotional distress.”

The Director of Nursing, when confronted with the evidence, admitted that if antibiotics are not given as prescribed, a resident’s health status “could get worse or develop a serious infection.” She confirmed that the facility’s expectation is that “all orders are transcribed accurately and are carried out” – an expectation that clearly wasn’t met in this case.

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.

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