The Illinois Department of Health has cited and fined Evercare of Breese when, according to state investigators and facility records, two residents sustained fractures after the facility failed to properly transfer them during incidents involving staff assistance — one when a wheelchair moved during a one-person transfer and the resident fell to the floor, sustaining a fracture of the hip; and another when she lost her balance during a walk to the dining room as the certified nursing aide stepped away to place a chair alarm. Both residents were transferred to the hospital for further evaluation and treatment.

The first resident was a 96-year-old woman with multiple chronic conditions including chronic obstructive pulmonary disease, chronic kidney disease, and significant cognitive impairment. She had been assessed as requiring substantial to maximum assistance for transfers. According to the citation, a certified nursing aide was transferring her from her bed to her wheelchair as a one-person assist with a gait belt. The aide stated she made sure the resident had gripper socks on, used a gait belt, and confirmed the wheelchair was locked. When she stood the resident up, the wheelchair rolled backward, and the resident ended up on the floor on her side. The facility’s progress note documents that the wheelchair did not fully lock on the right side and rolled backward during the transfer.

The resident initially denied pain after the fall, but within the hour began experiencing increased discomfort. An in-house X-ray was ordered, and the results showed a comminuted fracture of the left hemipelvis including a fracture through the acetabulum and a fracture of the inferior pubic ramus. She was sent to the emergency room and returned with a diagnosis of a closed fracture of the left hip.

Approximately two weeks after the hip fracture, the same resident experienced another transfer incident. Two certified nursing aides attempted to transfer her from her bed to her wheelchair using a gait belt as a two-person assist. According to one aide’s account, when they stood the resident up she became “dead weight,” her knees buckled, and the aides slowly lowered her to the floor. No injuries were reported from this incident, but the resident was subsequently downgraded to a mechanical lift for all future transfers.

The second resident was a woman with chronic obstructive pulmonary disease, type 2 diabetes, macular degeneration, blindness in one eye, low vision in the other, and a history of falls. She was assessed as needing substantial to maximal assistance with transfers and was on a care plan calling for one-person assist with a gait belt and assistance any time she ambulated with her walker. On the day of the fall, a certified nursing aide walked her to the dining room using a gait belt and walker. When they reached her seat at the dining table, the aide stepped away to place a chair alarm in the resident’s chair. As the aide did so, the resident lost her balance and fell in the direction away from the aide. The aide reported the resident said “oh, oh” and was already falling before the aide could intervene. She was holding onto her walker at the time of the fall.

The resident was transported to the hospital, where imaging confirmed a comminuted displaced fracture at the distal radial meta-diaphysis with approximately 30 degrees of dorsal angulation, along with a mildly displaced ulnar styloid fracture. The Nurse Practitioner told investigators that she would expect residents to be transferred safely and equipment to be safe.

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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Axiom Healthcare of West Frankfort when, according to state investigators and facility records, a resident with Parkinson’s disease and a long history of falls sustained a closed fracture of the left orbit and left maxilla after the facility failed to consistently implement the fall prevention interventions documented in his care plan. The resident had fallen at least sixteen times in the three months leading up to the injury, and investigators repeatedly observed during the survey that documented fall interventions — including keeping the call light within reach and wrapped with yellow tape — were not being followed.

The resident was a cognitively intact man with Parkinson’s disease, muscle wasting, and a need for assistance with daily care. According to the citation, he had a documented brain bleed from a prior fall before the events described in the survey, and his care plan listed more than two dozen interventions designed to reduce his fall risk over a period of several months. These included keeping the call light within reach and wrapped in yellow tape as a visual reminder, ensuring the bed was kept in the lowest position, moving him closer to the nurses’ station, conducting 15-minute checks, providing grippy socks and proper footwear, and assisting him with all transfers.

Over the course of approximately three months, the facility’s own fall investigation reports documented at least sixteen separate falls — sometimes more than one in a single day. Multiple falls involved the resident leaning forward out of his wheelchair, attempting to retrieve items off the floor on his own, transferring without staff assistance, or being unable to wait for help. After one fall the resident hit his chin on the floor and broke teeth. After another the staff documented they could not locate the resident’s broken teeth in the room.

On the morning that resulted in his serious facial injury, a nurse found the resident on the floor beside his bed without footwear in place. The initial assessment found no injuries and the resident denied hitting his head. The nurse applied grippy socks, returned him to bed, and began neurological checks. Approximately two hours later, a follow-up note documented small swelling to the resident’s left cheek. Several hours after that, the swelling had progressed to left-sided facial and orbital swelling and bruising, and the resident reported head and neck pain. He was sent to the hospital, where imaging confirmed a closed fracture of the left orbit and a closed fracture of the left maxilla. Several days later he was sent to the hospital again after another fall, where imaging incidentally revealed an old thoracic spine fracture of unknown origin.

During the survey, investigators directly observed multiple instances in which the documented fall interventions were not being followed. On separate occasions over several days, investigators observed the resident’s call light placed out of reach — on top of a nightstand, on top of positioning devices, and approximately four feet from where the resident was lying. The yellow tape that was supposed to be wrapped around the call light as a visual reminder was not observed on any of these occasions. The resident’s door was repeatedly observed closed, with no staff in the room. Investigators also witnessed the resident wheel himself out of the dining room with no staff in sight, get his wheelchair caught on a doorway, stand up from his wheelchair, become tangled in his catheter tubing, and walk down the hallway with an unsteady gait pushing his wheelchair from behind — without any staff assistance observed by investigators. A housekeeper was the first to call out for staff to help. It took approximately one minute for three staff members to respond.

A licensed practical nurse told investigators directly that the resident has a lot of falls, especially on the night shift, that he seems like a different person at night, and acknowledged that on some bad nights the 15-minute checks might not all get done. The Assistant Director of Nursing told investigators she was not aware any residents were currently on 15-minute checks, that she would expect the resident’s call light to be in reach when he is in bed, that she would expect his door to be open unless staff were in the room providing care, and that he was supposed to have yellow tape around his call light so he could find it easier. The MDS coordinator stated she was trying to come up with new fall interventions for the resident and other residents, but acknowledged she did not know if the interventions she had put in place were working.

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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Montgomery Place, a nursing home in Chicago when, according to state investigators and facility records, a certified nursing aide performed a sit-to-stand mechanical lift transfer alone — without a second staff member present despite the resident being assessed as dependent for transfers requiring two or more helpers — and the 96-year-old resident slid off the bed during the transfer with her legs becoming tangled underneath her, resulting in a right femoral fracture. The resident, who was fully dependent on staff for transfers, was hospitalized following the incident.

The resident had been at the facility for over a year, originally admitted following a fall that resulted in a tibia and fibula fracture. She had a long medical history that included a prior history of falls, generalized muscle weakness, spinal stenosis, polyosteoarthritis, and reduced mobility. Her most recent assessment classified her as dependent for transfers — meaning, per the assessment definition, the assistance of two or more helpers was required. Her fall risk evaluation classified her as high risk for falls. Multiple staff members confirmed she had poor trunk control, could not sit up unassisted for long, and could not bear weight on her legs.

On the morning of the incident, a certified nursing aide working the overnight shift was transferring the resident from her bed to her wheelchair using a sit-to-stand mechanical lift. According to the aide’s own account, she had properly applied the lift’s belt and sling, positioned the resident’s feet on the base, and pressed the up button. As the resident began to lift off the bed, she jerked forward. The aide attempted to lower her back down, but during this process the resident’s buttocks slid off the bed, and her right foot came off the lift’s foot base. The aide lowered the resident toward the floor. By the time the lift had lowered, the resident’s right leg had bent inward and was twisted underneath her body. She came to rest in a seated position on the floor with her right leg folded beneath her.

The aide left the room to find another certified nursing aide to help her. When they returned, they got on either side of the resident and lifted her back into bed. The resident was screaming in pain and complaining repeatedly about her foot, her knee, and her leg. The nurse coming on duty was notified, the resident’s physician was called, and the resident was sent to the hospital by ambulance. The hospital diagnosed her with a right periprosthetic femoral shaft fracture — a fracture of the thigh bone at the site of her artificial knee joint.

Investigators also learned that the aide routinely transferred the resident alone using the sit-to-stand lift. The aide who performed the transfer told investigators that while staff are instructed to use mechanical lifts with two people, she had been using the sit-to-stand on her own because people were not always available to help her, and she had never had a problem doing it on her own before. The second aide who came to help after the fall confirmed in her own interview that this aide routinely got the resident up out of bed by herself using the sit-to-stand lift, stating she knew this because she had never been asked to help with that resident’s transfers.

Multiple staff members agreed the injury may have been prevented if a second person had been present. The aide who performed the transfer told investigators directly: “If there were two CNAs there that morning, it could have prevented the resident from getting injured. Two CNAs could have prevented her from sliding off the bed and with two people we would have been able to get her back onto the bed instead of having to lower her to the floor.” The Director of Nursing acknowledged that under the assessment definition of dependent — which means the resident requires the assistance of two or more helpers — the resident should have had at least two staff members assisting with the sit-to-stand lift. The therapy director, the medical director, the registered nurse, and the Director of Nursing all stated that two staff members should assist during mechanical lift transfers for safety.

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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Heartland Senior Living in Neoga, Illinois when a resident’s bathroom call light was not promptly answered while one staff member stood at the nurses’ station and was not paying attention to the call light panel and another assumed someone else would respond. The resident, who had been identified as a fall risk requiring staff supervision, attempted to stand from the toilet without assistance, lost her balance, fell, and was found unresponsive on the bathroom floor with swelling and bleeding on both sides of her brain.

The resident had been identified as a fall risk and required staff supervision due to an unsteady gait and safety concerns with transfers and ambulation. On the day of the fall, she activated her bathroom call light. A certified nursing aide who was passing meal trays noticed the call light was flashing and sounding. She later told investigators she assumed another aide — who was standing at the nurses’ station at the time — would answer it, so she continued passing trays on a different hall. When she returned to the resident’s hall, the call light was still flashing and sounding. She entered the room and found the resident lying flat on her face on the floor, unresponsive. She estimated that approximately seven minutes had passed from the time she first noticed the call light to the time she finally answered it.

Meanwhile, the aide who had been standing at the nurses’ station told investigators she had not been paying attention to the call light panel because she believed most of the residents were in the dining room eating dinner. After review, staff determined the resident had attempted to stand from the toilet on her own, lost her balance, and fallen. She was bleeding from a skin tear on her left arm. The licensed practical nurse who responded called Emergency Medical Services. When paramedics arrived and tried to move the resident, she complained of pain in her right shoulder. She was transported to the local emergency room, where a head scan documented acute swelling and bleeding on both sides of her brain.

The Director of Nursing told investigators he was aware the resident was a fall risk and that staff would have been as well, since all newly admitted residents are treated as being at risk for falls. He stated his expectation is that any staff member aware of a call light should respond immediately unless actively assisting another resident, in which case the light should be answered within five to eight minutes. He stated specifically that the aide passing trays should have communicated with the aide at the nurses’ station to make sure the call light was being answered, that she should have sought assistance before finishing her tray pass, or that she should have answered the call light herself.

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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Fair Oaks Health Care Center in Crystal Lake, Illinois when two certified nursing aides improperly attached a mechanical lift sling, causing the sling to come loose mid-transfer and the resident to fall to the floor, sustaining a subdural hematoma — a bleed on the brain — that required hospitalization. The investigation determined the sling loop came off the hook because one aide had wrapped the excess strap around the end of the lift bar, creating tension that caused the loop to pop free while the resident was being moved over the wheelchair.

The resident was a 75-year-old woman who had been admitted to the facility the previous month. Two certified nursing aides were working together to transfer her from her bed to her wheelchair using a full mechanical lift. One aide hooked her side of the mechanical lift sling onto the lift bar and then wrapped the remaining strap around the end of the lift bar — a step that was not part of correct procedure. When the resident was raised and moved toward the wheelchair, the sling came undone and she fell to the floor.

Both aides described what happened consistently during interviews with investigators. One stated she had hooked the loop of the sling on the lift bar and wrapped the rest around the outer hook of the bar, and that when the resident was lifted and moved toward the wheelchair the sling came undone and the resident fell. The Administrator confirmed that after interviewing both aides they were able to recreate the failure: when the loop strap was wrapped around the end of the transfer bracket it created tension that popped the loop off the hook.

The resident was hospitalized and a CT scan showed she had sustained a 3-millimeter subdural hematoma — a bleed between the brain and the skull — as well as bruising to the scalp. She was discharged from the hospital and readmitted to the facility several days later with a new diagnosis of traumatic subdural hematoma. The facility’s own Safe Resident Handling and Transfers Policy, in place at the time of the incident, required staff to maintain compliance with safe handling and transfer practices. The improper attachment of the sling was inconsistent with that requirement.

Following the incident the facility took corrective action, including providing formal retraining to both aides involved on the day of the incident, conducting facility-wide in-services with video training and return demonstrations for all staff, developing an addendum to the safe handling policy, and requiring agency staff to complete online training and pass a return demonstration with the physical therapy department before being permitted to work on the floor.

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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Fair Havens Senior Living in Decatur, Illinois when a resident’s wheelchair was improperly secured in the facility’s transport van by a driver who had not been adequately trained on the manufacturer’s wheelchair securement system, causing the resident’s wheelchair to flip forward and the resident to slide onto the floor of the van as it drove down a hill, resulting in multiple leg fractures and a 17-centimeter laceration requiring eight sutures. The state issued an Immediate Jeopardy citation, the most serious level of violation.

The resident at the center of this case used a wheelchair for mobility and required staff assistance for her activities of daily living. She was being transported to a physician appointment in the facility’s transport van. The van driver loaded her into the van, secured her wheelchair, fastened the lap belt, and began driving down the hill in front of the facility. Almost immediately, the resident later told staff, she felt her wheelchair move and called out to alert the driver. The driver told her she would be ok and continued driving.

Within moments the resident was screaming. The driver looked in her rearview mirror and saw the resident leaning forward in the wheelchair, bracing herself against the seat next to her. The driver later said in her own words: “I was pulling away from the building when I heard her screaming. I looked in the rearview mirror and saw her leaning forward in the wheelchair, bracing herself on the seat next to her. I drove back around to get help; she couldn’t hold herself up. Her leg went back underneath her, and blood was everywhere.” Rather than stopping immediately, the driver drove the van around the parking lot back up the hill to the facility’s main entrance to get help.

When the Director of Nursing and a licensed practical nurse reached the van, they found a scene the nurse later described as resembling a car accident. The wheelchair had tipped forward. The resident was on the floor of the van with her left leg bent under her body, blood pooling beneath her. The seatbelt and wheelchair attachments were under such tension from the resident’s body weight that staff had difficulty unlatching them. Once they freed her and placed her flat on the van floor, they discovered a large laceration to the top of her left shin. She was alert and oriented and complained of severe pain in her left leg. Emergency Medical Services arrived and transported her to the hospital. Imaging revealed multiple fractures: a fracture of the upper tibia, a fracture of the fibular head, a fracture of the distal fibula extending to the ankle, and an additional avulsion fracture. The 17-centimeter laceration on her leg was closed with eight sutures.

The investigation revealed that the driver had not been properly trained on the manufacturer’s wheelchair securement system. When investigators observed the driver loading another resident into the van for transport, she attached the securement straps to the wheelchair’s armrests rather than the wheelchair frame, used straps that were twisted, and positioned the straps at a 65-to-75-degree angle. The manufacturer’s manual specifies that the tie-down hooks must be attached to a solid wheelchair frame — explicitly not to spokes, wheels, or movable components — and at an approximate 45-degree angle. The driver acknowledged she had attached the restraints to the armrests and stated this was how she always restrained residents for transport.

When asked about her training, the driver stated she had not been formally trained on driving the van or securing residents and had only received a packet with a safety checklist. The Maintenance Director, who was listed as her trainer, was unable to give an accurate demonstration of the actual securement system used in the transport van, demonstrating instead a different system. He acknowledged the j-hooks should be attached only to the wheelchair frame, not the armrests. The driver’s training records included a form dated the day after the incident that was a photocopy with the trainer’s signature already on it and the driver’s name handwritten in. The driver confirmed she had not actually received the training documented on that form. A third resident interviewed by investigators stated the same driver had restrained his wheelchair using the armrests as the anchoring point on multiple prior occasions. The Administrator confirmed the facility did not have a transportation policy at the time of the incident.

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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Evercare at Edwardsville when two residents were injured during transfers — one because a certified nursing aide transferred her without the required gait belt, causing her to fall and fracture her left upper arm, and a second because a mechanical lift sling hook was not properly secured, causing the resident to slip out and strike her head. Both injuries were preventable and both violated the facility’s own transfer policies.

The first resident had a below-the-knee amputation on her left leg and significant weakness, making proper transfer technique critically important. Her care plan required extensive assistance for transfers due to her weakness and impaired mobility. During a transfer from wheelchair to bed, the resident shifted her weight to her left side — the side with the amputation — lost her balance, and fell. The certified nursing aide who was performing the transfer stated she had been told by other aides that this resident preferred a “bear hug” transfer method, and on that basis she was not using a gait belt. The resident sustained a fracture of the left humeral neck and was sent to the emergency room. The facility’s transfer policy states explicitly that use of a gait belt for all physical assist transfers is mandatory. The Administrator confirmed she would expect staff to follow that policy.

The second resident had Alzheimer’s disease, muscle weakness, and was fully dependent on staff for all transfers. Her care plan required a full mechanical lift with two staff members for all transfers. On the morning of the incident, the certified nursing aide on duty stated the facility was extremely short-staffed and that she asked multiple staff members to help her with the mechanical lift transfer and no one would assist her. She proceeded to perform the transfer alone. While lifting the resident, the sling hook came unhooked, and the resident slipped out of the sling and struck her head on the floor. The resident sustained a hematoma to the back of her head, complained that her head hurt, and was transported to the emergency room by ambulance. The hospital noted the resident had fallen approximately four feet. The Director of Nursing confirmed the hook was not completely secured before the lift began and that the staff member was performing the transfer by herself — in direct violation of the care plan requirement for two-person assist.

Taken together, both incidents reflect the same core failure: staff did not follow documented transfer requirements, and residents were seriously hurt as a result. The facility’s own policies required mandatory gait belt use for all physical assist transfers and two-person mechanical lift transfers for residents who cannot be safely transferred otherwise. In one case a staff member substituted an informal technique based on secondhand advice from colleagues. In the other, a staff member proceeded with a high-risk transfer alone after being unable to find a second person to assist her.

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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Elevate Care Country Club Hills when a certified nursing aide transferred a resident who required two-person assist for all transfers without a second staff member present, causing the resident to slide to the floor and sustain a fractured left ankle requiring hospitalization. The resident’s care plan had clearly documented the two-person transfer requirement, and multiple assessments had confirmed she was fully dependent on staff for transfers — but the aide performed the transfer alone.

The resident was a 57-year-old woman with a complex set of diagnoses including cerebral palsy, spastic hemiplegia, vascular dementia, schizophrenia, bipolar disorder, and generalized anxiety, among others. She had been a long-term resident of the facility. Her condition included significant weakness on her left side, and she wore an Ankle Foot Orthosis brace on her left foot to support her mobility. Multiple assessments documented over the preceding months consistently showed she was fully dependent on staff for transfers and required two staff members to assist her safely.

The resident’s care plan was explicit on this point. An entry from over a year before the fall specified moderate to substantial assist with two staff members and a gait belt for all transfers due to increased weakness and behaviors. A later entry directed staff to use a full body mechanical lift with two-person assist for all transfers. These requirements were based on her assessed needs and known fall risk.

On the day of the fall, a single certified nursing aide attempted to transfer the resident from her bed to her wheelchair alone. The resident described what happened clearly when interviewed by investigators: the wheelchair was not positioned correctly, the aide grabbed her from under the arms and stood her up, and then let go of her on her left side. The resident said that is when she slid down to the floor. She was wearing her AFO brace at the time, and when she hit the floor she heard a cracking sound and told staff her leg hurt. She was hospitalized and diagnosed with a closed fracture of the left tibia and fibula.

When investigators interviewed staff, the failures ran deeper than a single aide’s decision. The nurse on duty at the time of the fall said she was unsure what the resident’s transfer status was. Another nurse stated she was not even aware the care plan required a two-person transfer. The Director of Nursing and the Administrator both confirmed that care plan interventions are expected to be followed by all staff — but the documented requirement had not been followed, and at least one nurse did not know it existed. The facility’s own fall prevention policy and transfer policy both required that transfer needs be documented in care plans and that staff follow those documented requirements. Neither happened on the day of the fall.

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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Arc at Streator in Streator, IL when a resident fell out of a mechanical lift sling during a bed-to-wheelchair transfer, landing on his head and left shoulder while his right leg remained caught in the sling, and sustained a right distal femur fracture and multiple spinal compression fractures requiring surgery. The sling’s upper hook came unlatched during the transfer, and the resident, who had a known tendency to grab at the sling during transfers due to anxiety, fell to the floor before staff could catch him.

The resident had a complex medical history including a prior stroke affecting the left side of his body, epilepsy, anxiety, chronic kidney disease, hypertension, and a prior amputation of toes on his right foot. He required a two-person mechanical lift transfer for all bed-to-chair movements. On the morning of the incident, the resident’s family asked staff to transfer him to his wheelchair for a visit. The assigned certified nursing aide’s usual partner was on lunch break, so she asked a registered nurse to assist her instead.

The two staff members secured the resident into the mechanical lift sling, checking that the loops were attached to the hooks. The CNA then leaned over the bed to move the resident’s catheter bag out of the way. The nurse began pulling the mechanical lift away from the bed. According to the CNA, the lift became caught on a cord under the bed and jerked slightly. The upper left hook of the sling came unlatched, and the resident fell rapidly to the floor, landing on his head and left shoulder. His right leg remained caught in the sling. Staff yelled out, and the CNA rushed toward him trying to catch him, but the fall happened too fast. The resident did not cry out.

The nurse described the scene: “The left upper hook came unhooked, and he went to the floor really fast. She ran and tried to hold his head but his left shoulder and his head hit the floor, and his right leg was still in the sling. We lowered the sling to the floor and got him out of it. He did not yell or call out. He was very startled, we all were.” Staff immediately called for help and called 911. The resident’s family, who had been waiting in the hallway, came into the room. The nurse called the resident’s wife, who was his power of attorney. Paramedics arrived within minutes and transported him to the emergency room.

Despite the severity of the fall, the resident remained alert and communicative throughout. He was talking to staff on the floor, and as the CNA later recalled: “He was talking to me and trying to have a conversation with me.” When interviewed by investigators weeks later, the resident described the incident in his own words, referring to the mechanical lift as a “foyer”: “I have some pain in the back of my head from where they dropped me out of the ‘foyer’ onto the concrete floor.” He also said: “I am not crazy about the ‘foyer’ after that fall, but I got up this morning for breakfast.”

Hospital imaging revealed the full extent of his injuries: a displaced right distal femur fracture requiring surgery, along with acute and subacute compression fractures at multiple levels of the spine, and severe osteopenia throughout the spine. He underwent surgical repair of the femur fracture two days after the fall. The spinal compression fractures were managed with a brace when out of bed, with neurosurgery determining no acute surgical intervention was needed.

The facility’s own investigation identified the resident’s tendency to grab at the sling as a contributing factor, noting he had a known behavior of fidgeting with the sling due to anxiety during transfers. His care plan, updated the day after the incident, reflected this: “I have a behavior of grabbing at the sling due to being anxious while being transferred by the mechanical lift,” with an intervention to give the resident an object to hold to occupy his hands. Notably, this intervention was only added after the fall — not before it, despite the behavior being known to staff. The CNA herself recalled telling him before the lift to put his arms across his chest.

Following the incident the facility took corrective action, including auditing all mechanical lifts and slings, removing three slings with frayed loops or seams from service, reassessing all residents requiring mechanical lifts, and providing additional training to all direct care staff on proper mechanical lift use. Further training from an outside agency on proper transfer techniques and equipment inspection was provided to all nursing and CNA staff in the weeks that 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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Alden Lincoln Rehab and Healthcare Center when a certified nursing aide left a resident who required supervision alone in the shower room to answer another resident’s call light, and the resident fell and sustained multiple pelvic fractures that required hospitalization and surgery consultation. The resident, who was cognitively intact and able to clearly describe what happened, told investigators he needed help in the shower and that staff normally stayed with him — but on this occasion no one was there when he fell.

The resident had a complex medical history that made his need for supervision during showering especially important. His diagnoses included multiple prior pelvic fractures, heart failure, atrial fibrillation, diabetes, and muscle weakness, among other conditions. His care assessment documented that he required partial to moderate staff assistance during showers. He was cognitively intact and well aware of his own needs. He used a rollator walker and had been functioning with a degree of independence prior to this incident.

On the morning of the fall, a certified nursing aide was accompanying the resident to the shower room. She noticed another resident’s call light going off. Rather than asking a colleague to respond to the call light or waiting until the resident was safely supervised, she instructed the resident to wait and left to answer it herself. The resident, standing in the shower room, leaned over to try to remove a tight sock from his foot and lost his balance. He fell to the floor. No staff member was present.

When the aide returned and found the resident on the floor, she notified the nurse. The resident told staff he thought he had hit his head. Because he was on multiple blood thinners, the nurse practitioner ordered him sent to the hospital immediately. He was transported by ambulance and admitted to the hospital, where imaging revealed multiple fractures to the right hip and pelvis. Surgeons were consulted but determined he was not a candidate for surgery at that time. He was left to heal without surgical intervention.

The resident described the incident clearly to investigators: “I was trying to take a shower, and I could not get my sock off my foot. the certified nursing aide left the shower room and said she would be back. I leaned over and fell on the floor. I do need help in the shower — staff normally stay with me in the shower in case I need help. When I fell, no one was in the shower room with me.” He also shared the lasting impact on his life: “Since I am no longer able to walk around with my rollator, I must depend on staff more for my care. This makes me feel helpless.”

Every staff member interviewed agreed that the resident should not have been left alone. The aide herself acknowledged it: “I don’t think the resident would have fallen if someone was with him.” She stated she could have asked another staff member to answer the call light but believed she could do it quickly and return. The registered nurse on duty said he was never informed the resident was going into the shower — which was itself a protocol violation — and that the aide should have stayed with the resident and asked someone else to handle the call light. The nurse practitioner stated that a staff member should have been with the resident in the shower room to reduce the risk of a fall. The Director of Nursing was direct: staff are required to have everything they need before entering the shower room with a resident, and residents requiring supervision should not be left alone.

The consequences for the resident were significant and lasting. Prior to the fall he had been moving independently with a rollator walker. Afterward, he was restricted to toe-touch weight bearing, could no longer use his rollator, and required a mechanical lift for transfers. He was moved to a higher-acuity unit for increased supervision. He also continued experiencing pain but had stopped taking his prescribed pain medication because it caused constipation — a side effect he found more debilitating than the pain itself. The physical therapist noted that while the resident was progressing, healing from multiple fractures takes time, and diabetes can slow the process further.

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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Alden Estates of Orland Park when a resident with moderate dementia on a locked memory care unit was left without adequate supervision, fell twice in a short period, and sustained a head laceration requiring staples on the first fall and a fractured femur on the second. Staff were aware the resident was impulsive and prone to attempting to stand and walk unassisted, yet failed to maintain the visual oversight her condition required.

The resident lived on the facility’s locked dementia unit and came with a serious set of risk factors: a diagnosis of dementia with psychotic disturbances, a history of falling, orthostatic hypotension and syncope. Her cognitive assessment documented moderate dementia, with severely impaired decision-making. She frequently tried to get up and walk on her own without calling for help, and staff were well aware of this behavior. Progress notes from the days surrounding the incidents describe her as restless, agitated, crying, yelling at staff, and repeatedly attempting to stand up unassisted despite redirection.

The first fall occurred when the resident, who had been seated in her wheelchair at the nurses’ station, made her way undetected into a staff-only room — a nurses’ closet that required a keypad code to enter and was meant to remain closed at all times for exactly this reason. She apparently entered when a staff member left the door open. Inside, she attempted to use the bathroom, stood up from her wheelchair, lost her balance, and fell. She was found on the floor with bleeding from the back of her head. She was transported to the hospital by ambulance, where a half-centimeter laceration was closed with two staples. A nurse who reviewed the incident said simply: “Someone must have left the door open.”

Shortly after, the resident fell again — this time in the dining room during dinner, with multiple staff present. She had been brought to the dining room in her wheelchair and her wheels were locked. Despite this, according to staff accounts, she pushed herself up from the chair, maneuvered around the wheelchair, and began walking around the table on her own. A staff member noticed her standing and immediately turned to set down a food tray before moving to assist her. By the time she turned back, the resident had already fallen. No staff member witnessed the actual fall. She was found on the floor near her table, with visible swelling to her left leg and pain rated at 8 out of 10. She was transported to the hospital, where an X-ray confirmed a midshaft left femur fracture.

The pattern across both incidents was the same: a resident known to be impulsive, restless, and prone to attempting to stand without assistance was not kept within consistent visual range of staff. The facility’s own memory care coordinator acknowledged that during mealtimes, there was no staff member designated specifically to monitor the dining room — staff were occupied passing out trays and attending to other residents’ needs. A nurse stated that if a resident was trying to get up and ambulate, that would warrant one-to-one monitoring. The nurse practitioner said she would expect staff to be within close visual range and to intervene when this resident exhibited those behaviors. Neither happened.

The facility’s fall management policy required individualized assessment of each resident’s specific risk factors and implementation of preventive interventions tailored to those risks. The care plan did include an intervention added after the first fall to monitor the resident for attempts to get out of her chair and redirect her accordingly. But monitoring and redirection are only effective when staff are close enough to act in time — and on both occasions, they were not.

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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Alden Courts of Waterford when a newly admitted resident with a documented history of falls, dementia, and a pre-existing neck fracture was left without adequate supervision and fell within his first full day at the facility, sustaining a fractured femur and an acute subdural hematoma that required admission to the intensive care unit. The facility knew he was at high risk for falls from the moment he arrived, but failed to put individualized supervision measures in place to protect him.

The resident arrived at the facility late in the evening and came with a serious medical history: a recent neck fracture from a prior fall, dementia, and a documented history of falls. His admission paperwork flagged him as being at HIGH RISK for falls. Staff who were interviewed confirmed they were well aware of the protocols required for high fall risk residents — keeping them in the line of sight of staff, placing them in common areas when awake, and checking on them every fifteen to thirty minutes when in their rooms. The Assistant Director of Nursing acknowledged that he was agitated when she first met him and that “more frequent rounds could have been done.”

The care plan created after his admission listed generic fall prevention interventions — a low bed, a call light within reach, proper footwear, and a clutter-free environment. Significantly, the Baseline Care Plan identified no cognition problems — yet his cognitive assessment completed that same day showed his cognition was severely impaired. That contradiction meant the care plan failed to account for his actual condition and contained no individualized supervision plan and no increased rounding schedule. For a resident with severely impaired cognition, relying on a call light as a primary safeguard was particularly problematic, as there is a serious question whether he could reliably use one at all. A certified nursing aide who worked with him that day recalled that while his family was present, he was already attempting to get out of bed on his own. Staff toileted him and helped him back into bed — but made no move to bring him to a common area where he could be watched.

After his family left for the evening, the resident was left alone in his room. According to the ambulance report, staff checked on him around 9:00 PM and then did not return for approximately fifty minutes. When they did, they found him sitting on the floor at the foot of his bed. He told them immediately: “My leg is broken.” He was right. He was sent to the hospital by ambulance, where imaging showed a right femur fracture. He was also admitted to the intensive care unit with a diagnosis of acute subdural hematoma — a serious condition involving bleeding near the brain — consistent with the trauma of a fall.

The facility’s own fall management policy required staff to assess each resident’s individual risk factors and develop a care plan with goals and interventions tailored to those specific risks. Multiple staff members confirmed that the standard protocol for high fall risk residents required checks every fifteen minutes when in their rooms and placement in common areas when awake. None of that happened for this resident. The facility’s final incident report attributed the fall to the resident not using his call light and having poor safety awareness — effectively placing the blame on a man with severely impaired dementia for not following instructions he may well have been cognitively unable to follow. The state disagreed, finding instead that the facility failed to provide the supervision this resident’s condition clearly demanded.

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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Accolade Healthcare of Pontiac in Pontiac, IL when a certified nursing aide performed a mechanical lift transfer alone — without the required second staff member — causing a resident to fracture her left knee. The resident endured weeks of pain, multiple emergency room visits, and an initial misdiagnosis before a CT scan finally confirmed the fracture.

The resident at the center of this case was fully dependent on staff for all transfers and was cognitively intact — meaning she understood exactly what was happening to her and could clearly describe it. In the early morning hours, a certified nursing aide used a total body mechanical lift to transfer her without calling for a second staff member, as the facility’s own policy required. The resident described what happened in her own words: the aide “was pushing on me, then suddenly I heard a pop and a crack.” When she told the aide something was wrong, he responded, “Look, you’re standing up.” The resident replied, “I haven’t stood up in years.” Her feet were touching the floor and her left knee struck the side of the bed during the transfer.

The resident was sent to the hospital that same night complaining of pain above her left knee. She was given powerful pain medications including fentanyl and Norco. The emergency room performed an X-ray, which came back negative for a fracture, and she was discharged with a diagnosis of a sprain. But the pain did not go away. Over the following days she continued to complain, continued to receive pain medication, and continued to tell staff that something was seriously wrong. When the nurse practitioner assessed her days later, the resident stated plainly that the aide had hurt her and that she knew something was wrong and wanted an MRI. The nurse practitioner noted she could be referred to orthopedics — at which point the resident, exhausted and in pain, began demanding that something be done immediately, saying she was “tired of this place.”

It took nearly two weeks and an orthopedic appointment with a CT scan to get the answer the resident already knew: she had a fractured left knee. The initial emergency room X-ray had missed it entirely. Throughout that period she had been living with an undiagnosed fracture, managed with pain medication rather than appropriate orthopedic care.

When investigators spoke to the aide, he confirmed without hesitation that he had performed the mechanical lift transfer alone, without a second staff member. The Director of Nursing confirmed that two staff members were required and that the aide had received disciplinary action. The Assistant Director of Nursing was equally direct: “A two-person transfer is required for all staff when using a total body mechanical lift.” The facility’s own hydraulic lift policy stated explicitly that staff must obtain assistance from a second staff member before performing such a transfer. That policy was ignored, and a dependent, cognitively intact resident paid the price with a fractured knee and weeks of unnecessary suffering.

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 Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.

The Illinois Department of Health has cited and fined Prairieview Lutheran Home in Danforth, IL when staff failed to identify and correct environmental hazards and wheelchair safety issues, resulting in two residents suffering serious fractures requiring surgery and emergency hospitalization. In both cases, the dangers were visible and preventable — and staff either walked past them or failed to address them before residents were seriously hurt.

The primary incident involved a resident who used oxygen via nasal cannula and slept in a recliner in her room. Her care plan identified her as a fall risk due to deconditioning, balance problems, a history of falls, and the use of psychotropic medications — and she required staff assistance with transfers and walking. The oxygen tubing ran across the floor from the bathroom to her recliner, and her call light cord stretched across the same path. These cords created an obvious trip hazard directly in the walking path of a resident the facility already knew was at risk for falling. No one moved them. No one rearranged the room. The hazard sat there unaddressed.

In the early hours of the morning, the resident got up on her own to use the bathroom. She tripped on the oxygen tubing, fell, and landed on her back on the floor. Staff found her when they heard her calling for help during routine rounds. She was taken to the hospital by ambulance, where she was found to have a broken hip and a broken arm. She underwent surgery the same day, receiving a partial right hip replacement and a long-arm cast. The Director of Nursing confirmed the root cause: the resident tripped over her oxygen tubing. As one nurse stated plainly during the investigation, “It was not in her best interest to have cords draped across the floor.” The room was rearranged after the fall — something that could and should have been done before it.

Making matters worse, after the fall staff lifted the resident off the floor manually — one person holding her shoulders, one her legs, and one her midsection — rather than using a full mechanical lift or waiting for emergency services. A certified nursing aide who witnessed it said the resident “screamed out in pain” during the transfer. The nurse practitioner stated it “would not be appropriate to arm-and-leg lift” the resident from the floor into bed, and the Director of Nursing confirmed that after any fall, a resident should be moved only with a full mechanical lift or, if the resident can bear weight, with a gait belt and two-staff assist. The resident could not bear weight.

The second incident involved a resident who was taken outside to the facility’s fall festival in her wheelchair by her husband. Before leaving, staff observed him struggling to position the wheelchair’s foot pedals correctly. He tried but could not attach them, and left them folded to the sides with the resident’s legs dangling unsupported in front of her. Multiple staff members walked past and said nothing. Video footage reviewed by the facility’s administrator confirmed this, and the administrator acknowledged that staff should have stepped in before they went outside.

Once outside, the husband pushed the wheelchair from the pavement onto the grass. The wheelchair became stuck, and without foot pedals to support and protect her legs, the resident’s foot caught under the wheelchair. She suffered a fracture of the left shinbone near the knee in two places, confirmed by both X-ray and CT scan. The facility’s own fall prevention policy specifically identified improperly fitted or maintained wheelchairs as an environmental fall risk factor. The Director of Nursing stated that any staff member who saw the situation should have stopped and corrected it before the resident was taken outside.

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.