The Illinois Department of Health has cited and fined Shelbyville Manor when a resident with dementia and a documented history of falls was allowed to walk unsupervised to the bathroom despite requiring substantial assistance with transfers, resulting in a devastating fall that broke both his hip and shoulder. The facility failed to provide adequate supervision […]
Resident Left Unsupervised, Falls and Suffers Double Fracture at Shelbyville Manor
Faulty Chair Alarm Leads to Fatal Fall and Hip Fracture at Prairieview Lutheran Home
The Illinois Department of Health has cited and fined Prairieview Lutheran Home when a severely cognitively impaired resident with a history of falls died after her chair alarm failed to alert staff when she attempted to get out of her electric lift chair, resulting in a fatal fall and hip fracture. The facility failed to […]
Pleasant View Luther Home Resident Suffers Neck Fracture After Tripping Over Wheelchair in Cramped Dining Room
The Illinois Department of Health has cited and fined Pleasant View Luther Home when an 82-year-old resident with Alzheimer’s disease and a history of multiple falls suffered a serious neck fracture after tripping over another resident’s oversized wheelchair in a poorly arranged dining room. The facility failed to provide adequate space for the high fall […]
Failure To Implement Fall Prevention Measures Leads to Resident’s Broken Hip and Head Injury at Goldwater Care Danville
The Illinois Department of Health has cited and fined Goldwater Care Danville when staff failed to implement required fall prevention measures for a severely cognitively impaired resident, resulting in a devastating fall that broke his hip and caused a head laceration requiring five staples. The facility’s Medical Director confirmed the fall was preventable and stated […]
Cognitively Impaired Resident Found 2.2 Miles Away After Nursing Home Staff Ignored Exit Alarm
The Illinois Department of Health has cited and fined Fondulac Rehabilitation and Health Care Center when a cognitively impaired resident with dementia walked out of the facility undetected and was found 2.2 miles away standing on a concrete median in the dark. The facility failed to follow its own safety protocols when staff dismissed a […]
Evercare at University Staff Ignored Resident’s Breathing Crisis, Calling It a ‘Panic Attack’
The Illinois Department of Health has cited and fined Evercare at University when nursing staff dismissed a 95-year-old resident’s severe breathing distress as a “panic attack” and failed to seek immediate medical attention despite dangerously low oxygen levels. The resident was eventually hospitalized on a ventilator after her family called 911, with emergency responders finding […]
Resident Suffers Hip Fracture After Being Over-Sedated to Prevent Wandering At Duquoin Nursing & Rehab
The Illinois Department of Health has cited and fined Duquoin Nursing & Rehab when a 92-year-old resident with severe dementia was given excessive doses of sedating psychiatric medications to prevent her from wandering, causing her to become unsteady and fall. The resident suffered a hip fracture requiring surgery after facility staff increased her anti-anxiety medication […]
Resident With Brain Injury Escapes Avantara Lake Zurich in Hospital Gown, Found Hypothermic Across Highway
The Illinois Department of Health has cited and fined Avantara Lake Zurich when a severely cognitively impaired resident with a traumatic brain injury escaped the facility through an unalarmed door and was found across a busy four-lane highway wearing only a hospital gown and diaper. The resident suffered hypothermia with a dangerously low body temperature […]
Resident Suffers Bone-Deep Infected Wound That Went Undetected Despite Daily Care at The Arc at Sangamon Valley
The Illinois Department of Health has cited and fined The Arc at Sangamon Valley when an 85-year-old resident with diabetes and cognitive impairment developed a severe stage 4 pressure wound that progressed to bone infection due to inadequate skin monitoring and care. The facility failed to properly assess, document, and treat the wound, leading to […]
Serenity Estates Resident Suffers Broken Arm After Getting Trapped Between Bed Rail and Mattress
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 […]
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