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Serenity Estates Resident Suffers Broken Arm After Getting Trapped Between Bed Rail and Mattress

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The Illinois Department of Health has cited and fined Serenity Estates of Lincolnshire when a 92-year-old resident with dementia became trapped between her bed rail and mattress, resulting in a broken arm. The facility failed to properly assess entrapment risks and obtain required consent before using bed rails as assistive devices.

The resident, who has dementia with agitation and typically requires partial to moderate assistance with transfers, was discovered in distress by nursing staff responding to a call light. However, the call light had been activated by her roommate, not the resident herself, as staff noted that the resident “never calls for help” and doesn’t remember to use her call light despite repeated reminders. When the Licensed Practical Nurse entered the room, she found the resident kneeling on the floor with her wheelchair positioned behind her and her right arm trapped between the mattress and side rail. The resident was complaining of severe pain and was unable to move her right arm.

The facility’s investigation revealed significant gaps in care and safety protocols. Staff members provided conflicting accounts of the resident’s transfer abilities, with some stating she could “safely transfer herself” while others noted she required “one-person extensive assist” and was “weak and does not ambulate.”

The Director of Nursing acknowledged that the resident was “high fall risk” but was uncertain whether proper consent had been obtained for the use of side rails. Multiple staff members noted that the resident “does not use her call light for assistance” and “needs to be supervised” because “if she is left alone, she will attempt to get up.” One nurse stated that “frequent monitoring and supervision could have prevented the incident.”

An inspection of the bed revealed a dangerous gap between the mattress and side rail that was “wide enough for her arm to fall through to get trapped.” This directly violated the facility’s own bed rail policy, which explicitly states that facilities must “ensure the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident’s head or body.”

The policy also requires informed consent from the resident or representative before installing bed rails, along with a physician’s order specifying the medical reason for their use. The resident’s care plan indicated she was supposed to use “bilateral half side rails to enhance functional independence,” but staff admitted uncertainty about whether proper consent had been obtained.

X-ray results confirmed the resident suffered a “comminuted fracture of the right humeral neck,” meaning her upper arm bone was broken in multiple places. She was hospitalized for treatment of this serious injury.
The resident’s fall risk assessment had previously identified her as having a “weak gait” and tendency to “overestimate or forget her limits,” yet appropriate preventive measures were not consistently implemented. The facility’s own policies required additional interventions for high-risk residents, including “increased frequency of rounds, sitter if needed, low bed, alternate call system access, and scheduled toileting assistance.” However, staff statements suggest these protocols were not adequately followed, with nursing personnel split between multiple units and the resident left unsupervised despite her documented need for constant monitoring due to her dementia and fall risk status.

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 Bradley Staff Ignores Lift Requirement, Resident’s Leg Snaps During Dangerous Solo Transfer

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The Illinois Department of Health has cited and fined The Arc at Bradley when a Certified Nursing Assistant attempted to lift a resident with multiple sclerosis by herself without using the required mechanical lift, causing the resident to fall and suffer a broken leg that required emergency room treatment and orthopedic follow-up.

The resident was admitted to the facility with several serious medical conditions including multiple sclerosis, lack of coordination, abnormal posture, reduced mobility, and chronic obstructive pulmonary disease. Due to these conditions, she had impairments to both her upper and lower extremities and was completely dependent on staff for transfers between her bed and chair.

Because of her physical limitations, the resident’s care plan clearly specified that for “Chair/bed to chair transfer: My usual performance is dependent. I use a mechanical lift for transfer assist.” Her Kardex Report, which is a quick reference guide for staff, also clearly stated “Transferring: Transfer- The resident is totally dependent on 2 staff for transferring.”

Despite these clear instructions, a Certified Nursing Assistant (CNA) attempted to transfer the resident without following proper protocol. When interviewed, the CNA admitted, “I was trying to lift [the resident] without a mechanical lift and with no assistance from another staff member.” The CNA further acknowledged that the resident “became too heavy, and I lowered her onto the floor.”

Most concerning, the CNA fully admitted that she was aware of the proper transfer procedure but chose to ignore it: “I had worked with [the resident] before and knew [she] transferred with a mechanical lift.”

After the fall, the resident immediately “was complaining of pain to her legs.” However, according to the resident, the CNA dismissed her concerns, telling her “Your leg is fine.” Despite this dismissal, the pain persisted, and a nurse practitioner was eventually notified. X-rays were ordered, which revealed an “acute nondisplaced proximal tib-fib fracture” – a break in both the tibia and fibula (the two bones of the lower leg) near the knee.

The resident was then sent to the emergency room for evaluation and treatment. Upon her return to the facility, it was noted that she would need follow-up care with an orthopedic specialist.

When interviewed, the Director of Nursing clearly identified the cause of the injury: “An investigation was done; [the CNA] used the wrong transfer technique.” The Director explained that the CNA “lifted [the resident] for the transfer by herself and did not use a mechanical lift,” while “the correct transfer technique for [the resident] is a mechanical lift with two assistance.” The Director emphasized that the CNA “knew very well that she should have transferred [the resident] with a mechanical lift and two assist,” and acknowledged that “when residents are not transferred appropriately, they could have a fall with injury to both the patient and the staff, adding in this case, the resident had a fall with an injury.”

The Nurse Practitioner who ordered the X-rays confirmed that the fracture “was the result of the CNA transferring the resident inappropriately” and stated that the injury “could have been prevented if the resident was transferred with a mechanical lift and two staff instead on one staff.”

The facility’s policies were clear on this matter. Their “Transfers- Manual Gait Belt and Mechanical Lifts Policy” stated that “Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique.” Similarly, their “Fall Prevention Program” policy specified that “Transfer conveyances shall be used to transfer residents in accordance with the plan of care.”

This incident represents a serious failure to follow established safety protocols that resulted in unnecessary harm to a vulnerable resident. Despite having moderate cognitive impairment, the resident was able to clearly articulate what happened and the pain she experienced as a result of the improper transfer technique. The injury was entirely preventable had the CNA simply followed the resident’s care plan and the facility’s policies regarding safe 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.

Sunny Acres Resident Left in “Excruciating Pain” for Over a Week When Pain Medication Not Refilled

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The Illinois Department of Health has cited and fined Sunny Acres Nursing Home when they failed to refill a resident’s critical pain medication patch for over a week despite her repeated requests for help. The cognitively intact 71-year-old resident, who suffered from arthritis and neuropathy, was left in “excruciating pain” for eight days without her prescribed Fentanyl patch, rating her pain as high as a seven out of ten (described as “as bad as it could be”).

The resident was a woman with multiple chronic pain conditions, including primary generalized osteoarthritis and neuropathy. According to her care plan, she was “at risk for pain related to arthritis, neuropathy, GERD.” Her treatment plan included a Fentanyl transdermal patch, a powerful opioid pain medication delivered through the skin, prescribed at 100 micrograms per hour to be changed every three days.

The facility’s Management of Pain Policy states that their mission is to “facilitate resident independence, promote resident comfort and preserve resident dignity” through “an effective pain management program.” The policy emphasizes “promptly and accurately assessing and diagnosing pain” and “monitoring treatment efficacy and side effects.” It specifically notes that pain should be considered the “fifth vital sign” along with temperature, pulse, respiration, and blood pressure. The policy defines pain as “whatever the experiencing person says it is, existing whenever the experiencing person says it does,” acknowledging the subjective nature of pain and the importance of taking residents’ reports of pain seriously.

Despite this policy, the facility failed to provide the resident with her prescribed Fentanyl patch for more than a week. During this period, the resident rated her pain at a level “five” or above eight different times, with at least one rating of seven out of ten, which the facility administrator later acknowledged “indicates pain that is as bad as it can be.”

The resident described her experience: “I wear a pain patch and I did not get my new patch. I kept asking the staff and nothing was done about it. I was told at one point that they needed to get a physician’s order. I don’t know if it was not followed up on or what happened.” She continued, “I was so upset because it had been well over a week that I had waited for the pain patch to be replaced. I was having stabbing pain in my neck and jaw I think from the stress from the amount of pain I was under. I thought I was having a heart attack. I was hurting and frustrated that no one would help me get my medication. I was in excruciating pain for over a week.”

A Certified Nursing Assistant confirmed the resident’s repeated pleas for help, stating, “Every time I would take her meal tray into her [during this period], she would complain of pain and say to me, ‘I just do not understand why they [the staff] are not getting me my pain patch and I have to go this long in pain.'”

Despite the facility’s policy requiring a comprehensive pain assessment when a resident scores five or above on the pain questionnaire, records showed only one comprehensive pain evaluation was completed during the eight-day period when the resident was without her pain medication. This evaluation documented her pain at level seven but noted “no new care plan interventions or clinical suggestions were made to address the resident’s pain.”

When interviewed, the facility’s pharmacist stated they “did not get a request to refill the resident’s Fentanyl” until more than a week after she ran out. The resident’s physician’s nurse confirmed that “our office should have been notified of the need for the Fentanyl Patch refill before the resident ran out.”

The facility Administrator acknowledged multiple failures in care, stating, “When the resident was out of her Fentanyl Patch somebody should have reached out to the physician to get the refill order or to see if the patch could have been pulled from back-up. The staff should have let the physician know that the resident was in pain and see if there was something else we could do to control the resident’s pain. The resident should not have had to go without her Fentanyl Patch.”

The Administrator further explained, “The staff should have contacted me or the Director of Nursing when the Fentanyl Patch was not available so one of us could have followed up on it. There is no documentation that the physician, me, or the Director of Nursing were notified of the resident going without her scheduled Fentanyl Patch or the resident’s complaints of pain.” The Administrator suggested that staffing issues may have contributed to the failure: “During this timeframe we had agency staff taking care of the resident who were not familiar with her. I think that is why there was no follow-up.”

This incident represents a serious failure to follow the facility’s own pain management policies and to provide appropriate care for a resident with chronic pain. The United States Food and Drug Administration Safety Communication specifically warns that “rapid discontinuation [of opioids] can result in uncontrolled pain,” yet the facility allowed this resident to experience an abrupt discontinuation of her pain medication for over a week without appropriate intervention.

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 Protect Resident from Roommate’s Violent Assault Results in Broken Finger at Southpoint Nursing & Rehab Center

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The Illinois Department of Health has cited and fined Southpoint Nursing & Rehab Center when they failed to protect a cognitively intact resident from a roommate with severe dementia who had a documented history of wandering, confusion, and aggressive behaviors. The assault resulted in the victim suffering multiple injuries including a fractured finger, shoulder deformity, and facial bruising.

The incident involved two residents sharing a room at the nursing facility. One resident had severe cognitive impairment with a Brief Interview Mental Status (BIMS) score of 3, indicating severe impairment. He had diagnoses including dementia, metabolic encephalopathy, and psychoactive substance abuse. His care plan noted that he “displays behavioral symptoms related to severe mental illness” with interventions including “Intervene when any inappropriate behavior is observed” and “Refer resident to consulting psychiatrist for a psychiatric evaluation as warranted.”

The other resident was cognitively intact with a BIMS score of 13 and had a care plan indicating that his “medical diagnosis may increase his susceptibility to abuse/neglect.” His interventions included “observe resident for signs of fear and insecurity during delivery of care” and “Assure the resident that staff are available to help, and department heads maintain an open-door policy.”

Progress notes for the resident with dementia documented escalating behavioral issues. Several weeks before the assault, notes indicated: “Resident wandering down hallway and went into another resident’s room. When staff asked resident to come out he became verbally aggressive and began yelling and cursing at staff that this was his house.” A few days later, another note stated: “Resident confused, leaves room and goes into other resident’s rooms walking about the hallway asking where is his room. Resident needs constant redirection.”

Despite these documented behaviors, the facility appeared to take insufficient action to protect other residents. When interviewed, the Social Worker described the resident with dementia as “just a wanderer, he was confused,” minimizing the seriousness of his behaviors.

On the day of the assault, a family member came to visit the resident with dementia. When the family member entered the room, she found the confused resident sitting in his roommate’s wheelchair. The roommate was sitting on the side of his bed leaning forward. When the family member asked if the roommate was alright, he informed her that the resident with dementia “had just jumped on him.” The family member attempted to speak with the resident with dementia, who became aggressive and defensive, prompting her to call for staff assistance.

When staff arrived and separated the residents, they observed the victim with “right 5th digit and shoulder deformity, and right eye discoloration” while the aggressive resident had a “scratch to left forehead.” Both residents were transferred to the hospital for further evaluation and treatment.

The victim later explained what happened: “I was assaulted in August, and I broke my little finger on my left hand. He asked me what was I doing in his house and before I could understand what he was saying to me, he swung at me. He said everything in here belonged to him.” Most concerning, the victim stated that he had been threatened for “about 2 weeks” prior to the assault, yet there was no documentation of these threats in the progress notes, suggesting a significant gap in monitoring and communication among staff.

Hospital examination confirmed that the victim suffered a “closed displaced fracture of proximal phalanx of left little finger.” The resident with dementia never returned to the facility after being sent to the hospital with petition paperwork for psychological evaluation.

The facility’s abuse prevention program states that “it is the policy of this facility to prevent resident abuse” and includes prevention measures such as “Resident and family concerns will be recorded, reviewed, addressed, and responded to using the facility’s concern/grievance procedure” and “Staff will identify residents with increased vulnerability for abuse, neglect, mistreatment or who have needs and behaviors that might lead to conflict.”

Despite these policies and the documented history of the resident with dementia wandering into other residents’ rooms and becoming verbally aggressive when redirected, the facility failed to implement effective interventions to protect his roommate from assault. The victim’s report that threats had been occurring for about two weeks prior to the assault suggests a serious failure in the facility’s monitoring and communication systems.

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 Femur Fracture After Being Pushed From Bed During Care at Aliya of Oak Lawn

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The Illinois Department of Health has cited and fined Aliya of Oak Lawn when a certified nursing assistant pushed a resident too hard while turning her during care, causing the resident to fall from the elevated bed and suffer a femur fracture that rendered her non-weight bearing for at least 12 weeks. The facility failed to provide proper safety equipment, including requested side rails, and failed to properly investigate the incident, incorrectly attributing the fall to the resident’s diagnoses rather than the staff member’s actions.

This case involves a resident who sustained a serious injury while receiving care in her room. According to the resident’s account, she was being changed by a certified nursing assistant (CNA) when the CNA “pushed [her] too hard and [she] fell to the floor.” The resident reported that the fall happened so quickly that she “did not have time to put her hands in front of her to prevent face from hitting floor.” She explained that the CNA had “raised the bed up higher before providing care,” which likely increased the risk and severity of the fall.

As a result of this fall, the resident suffered significant injuries, including “bruising to both arms and left leg, bruising and a lump above right eyebrow, and significant pain to left knee.” Hospital records confirmed the extent of her injuries, noting she had “a left condylar fracture with extension to the lateral femur metaphysis” and “a large lipohemarthrosis with hematoma measuring 7.5cm x 3.5cm x 2.2cm” as well as a “hematoma to forehead.” The resident was found to be anemic and required a blood transfusion during her hospitalization.

The resident stated that prior to this incident, she “was able to stand with assistance,” but following the fall, she became “nonweight bearing on left leg for at least 12 weeks.” According to her family member, this injury “has set [her] back at least six months” in terms of her recovery and functioning.

Notably, the resident reported that she had “requested side rails upon admission” months earlier but was told that “someone from therapy would assess her to see if side rails were appropriate for her.” However, she stated that “nobody ever did” conduct this assessment. The resident believed that “if she had side rails she could have possibly prevented or slowed down the fall.” Observations of her room confirmed that she had “no handle on [her] mattress” to hold onto when being turned by staff, despite the CNA reportedly instructing her “to hold onto the bed when turned.”

The facility’s account of the incident differed significantly from the resident’s. According to the facility’s investigation, the CNA stated that while “providing ADL care” and rolling the resident “over to her right side, [the resident] reached for an object on her bedside table and slid off the bed.” This version does not mention the CNA pushing the resident too hard or raising the bed height before providing care.

Further undermining the integrity of the facility’s response, the restorative nurse indicated that the facility had determined the “root cause of [the resident’s] fall was due to diagnoses of adult failure to thrive, anxiety disorder, fluid overload, and the need for extensive assistance with bed mobility.” When asked to clarify this assessment, the nurse responded, “I guess the root cause was determined to be due to [the resident’s] diagnoses and functional abilities” – effectively placing the blame on the resident’s medical conditions rather than examining staff actions.

Medical records indicate the resident has multiple serious health conditions, including “displaced fracture left femur, hemarthrosis left knee, metabolic encephalopathy, moderate protein-calorie malnutrition, liver transplant, critical illness myopathy” and several other conditions. Her Minimum Data Set assessment notes she “is totally dependent on staff for bathing, toileting, and personal hygiene,” highlighting her vulnerability and reliance on proper care.

Interestingly, a side rail review conducted weeks after the incident noted the resident “is appropriate to have 1/4 side rails to aid with bed mobility” – the very accommodation she had requested months earlier but never received.

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 Brain Hemorrhage After Fall From Bed at Ascension Resurrection Life

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The Illinois Department of Health has cited and fined Ascension Resurrection Life when staff left a 92-year-old resident with severe dementia unattended in an elevated bed, resulting in a fall that caused bilateral subdural hematomas and a subarachnoid hemorrhage requiring hospitalization in intensive care. The facility failed to follow proper safety protocols by leaving the cognitively impaired resident unsupervised with the bed in a raised position while the certified nursing assistant stepped away to get additional supplies.

This case involves a 92-year-old male resident with multiple medical conditions including dementia, osteoarthritis, unsteadiness on feet, lack of coordination, muscle weakness, and difficulty walking. According to his assessments, the resident had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of 01, indicating profound cognitive deficits. He was assessed as being at moderate risk for falls and required extensive assistance with bed mobility from two staff members.

The incident occurred during evening care when a certified nursing assistant (CNA) was providing incontinence care to the resident. According to the facility’s incident report, “The CNA rolled him on his right side and then stepped away to grab more wipes and soap to clean him. The CNA turned back towards and noticed he was leaning towards the edge of the bed. She quickly tried to get to the bed but [the resident] rolled off the bed hitting his head on the floor.”

When interviewed, the CNA admitted, “I put him on the potty, and he took a poo. I needed more material, so I went to the sink to get towels. When I turned around, I seen him falling and tried to catch him.” Critically, she acknowledged, “The bed was still up to about my hip. I did not let it [resident’s bed] back down…Yes, I should have all supplies available when I do care.”

The resident’s family member provided additional context, stating, “The CNA had the bed all the way up because she’s tall. She went to the sink to go get a rag and that’s when he fell. She shouldn’t have left the bed up like that and shouldn’t have left him at the edge of the bed.” The family member also expressed concern that the facility “didn’t fire her” but “just moved her to a different floor,” noting that the resident “has been at this facility for 4 years” and “has Alzheimer’s. They should know better.”

As a result of the fall, the resident sustained serious injuries. Hospital records documented “small acute bilateral cerebral convexity subdural hematomas measuring 5 mm on the left and 3 mm on the right” and “small right parietal subarachnoid hemorrhage measuring 7 mm.” The resident was admitted to the intensive care unit with “bilateral subdural hematomas and small right subarachnoid hemorrhage.”

The Interim Director of Nursing (DON) acknowledged that proper protocols were not followed. “Based off that, I began educating staff when residents are on a low air loss mattress, they should be a 2 person assist because when you’re on air mattresses they are constantly shifting.” The DON further explained what should have happened: “As a one person assist, she should have repositioned him on his back, centered, and lowered the bed. Don’t step away from the bed until lowered and positioned in bed. All those safety checks should have been done. If she would have done the safety checks the fall would likely not have happened.”

While the Administrator was “familiar with the incident,” when asked if the fall was preventable, they responded, “Possibly but I’m not a nurse,” and when asked if it caused harm, claimed, “I don’t feel it changed his condition. He has been declining. I’m not a nurse to assess and clinically cannot make that statement.” This contrasts with the Nurse Practitioner who, when asked if the fall caused harm, responded, “It didn’t help him. In a way yeah.”

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 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.

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