Safe Nursing Home Advocates

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Two residents at Bria of Wood River with tracheostomies died after staff performed CPR incorrectly by placing breathing ...
11/23/2025

Two residents at Bria of Wood River with tracheostomies died after staff performed CPR incorrectly by placing breathing bags over their mouths instead of their tracheostomy tubes because staff had never been trained how to resuscitate someone with a tracheostomy and either didn't have the correct equipment or didn't know how to use it.

An Accolade Healthcare of Savoy resident with heart and kidney disease was discharged from the hospital with orders to monitor her closely, but staff failed to report her dangerously low blood pressures, significant weight gain, and decreased urination despite repeated complaints from the resident a...

An Accolade Healthcare of Savoy resident with heart and kidney disease was discharged from the hospital with orders to m...
11/22/2025

An Accolade Healthcare of Savoy resident with heart and kidney disease was discharged from the hospital with orders to monitor her closely, but staff failed to report her dangerously low blood pressures, significant weight gain, and decreased urination despite repeated complaints from the resident and her family, resulting in acute kidney failure requiring dialysis and ventilation before she died.

An Accolade Healthcare of Savoy resident with heart and kidney disease was discharged from the hospital with orders to monitor her closely, but staff failed to report her dangerously low blood pressures, significant weight gain, and decreased urination despite repeated complaints from the resident a...

A Bridgeway Senior Living resident with a history of falls had her bed intentionally blocked on both sides by a nursing ...
11/21/2025

A Bridgeway Senior Living resident with a history of falls had her bed intentionally blocked on both sides by a nursing assistant who "boxed her into the bed so she wouldn't get up and fall," but the resident crawled out over the footboard, fell to the floor, and fractured her hip.

A Bridgeway Senior Living resident with a history of falls had her bed intentionally blocked on both sides by a nursing assistant who "boxed her into the bed so she wouldn't get up and fall," but the resident crawled out over the footboard, fell to the floor, and fractured her hip.

A Sunrise Skilled Nursing & Rehab resident receiving wound treatment was positioned on his side in an elevated bed and t...
11/20/2025

A Sunrise Skilled Nursing & Rehab resident receiving wound treatment was positioned on his side in an elevated bed and told by staff to hold onto the side rail while they left to get clean linens. Despite being completely dependent on staff for turning and repositioning, the resident was left alone holding the rail for an extended period until his strength gave out and he fell 36 inches to the floor. Staff gave him pain medication and sent him to his scheduled dialysis appointment, where the dialysis nurse immediately recognized the severity of his condition and called 911, leading to a two-week hospitalization for multiple fractures to both legs.

A Sunrise Skilled Nursing & Rehab resident receiving wound treatment was positioned on his side in an elevated bed and told by staff to hold onto the side rail while they left to get clean linens. Despite being completely dependent on staff for turning and repositioning, the resident was left alone....

A Clark-Lindsey Village high fall-risk resident with moderate cognitive impairment was left unattended on the toilet whi...
11/19/2025

A Clark-Lindsey Village high fall-risk resident with moderate cognitive impairment was left unattended on the toilet while a nursing assistant went to fix her bed in the same room. The resident attempted to stand on her own to get a wipe after voiding, fell on her left arm, and sustained multiple acute fractures to her shoulder and upper arm that required a brace and caused significant pain. Multiple staff members, including the nursing assistant involved, acknowledged that the resident should never have been left alone on the toilet given her documented fall risk.

A Clark-Lindsey Village high fall-risk resident with moderate cognitive impairment was left unattended on the toilet while a nursing assistant went to fix her bed in the same room. The resident attempted to stand on her own to get a wipe after voiding, fell on her left arm, and sustained multiple ac...

A Manor Court of Rochelle resident with severe dementia fell alone in the facility's dining room in the early morning ho...
11/18/2025

A Manor Court of Rochelle resident with severe dementia fell alone in the facility's dining room in the early morning hours while walking without supervision. Despite the resident complaining of back and side pain after the fall, the nurse on duty did not notify the physician, failed to perform required neurological checks, and failed to document pain medication administration. The resident spent the night in severe pain until the next morning shift discovered her condition and arranged emergency transport to the hospital, where X-rays confirmed a hip fracture.

A Manor Court of Rochelle resident with severe dementia fell alone in the facility's dining room in the early morning hours while walking without supervision. Despite the resident complaining of back and side pain after the fall, the nurse on duty did not notify the physician, failed to perform requ...

A severely cognitively impaired resident at Meadowbrook Manor - Naperville with eight previous unwitnessed falls in his ...
11/17/2025

A severely cognitively impaired resident at Meadowbrook Manor - Naperville with eight previous unwitnessed falls in his room and a care plan requiring increased supervision had a ninth unwitnessed fall while staff were in the dining room, resulting in a head injury that caused a massive seizure during ambulance transport and led to his admission to hospice care where he ultimately died.

A severely cognitively impaired resident at Meadowbrook Manor - Naperville with eight previous unwitnessed falls in his room and a care plan requiring increased supervision had a ninth unwitnessed fall while staff were in the dining room, resulting in a head injury that caused a massive seizure duri...

A resident at Newman Rehab & Health Care Center who required assistance with all activities including transfers and toil...
10/30/2025

A resident at Newman Rehab & Health Care Center who required assistance with all activities including transfers and toilet use turned on her call light to go to the bathroom, but when no one came to help her, she attempted to take herself and fell, fracturing her hip with moderate displacement and requiring hospitalization.

A resident at Newman Rehab & Health Care Center who required assistance with all activities including transfers and toilet use turned on her call light to go to the bathroom, but when no one came to help her, she attempted to take herself and fell, fracturing her hip with moderate displacement and r...

An Allure of Moline resident who had suffered a stroke required a pureed diet and constant supervision due to severe cho...
10/30/2025

An Allure of Moline resident who had suffered a stroke required a pureed diet and constant supervision due to severe choking risk, but staff allowed him to wheel himself out of the dining room unsupervised where he grabbed hot dogs and buns from a plate, stuffed them in his mouth, and choked to death despite emergency resuscitation efforts.

An Allure of Moline resident who had suffered a stroke required a pureed diet and constant supervision due to severe choking risk, but staff allowed him to wheel himself out of the dining room unsupervised where he grabbed hot dogs and buns from a plate, stuffed them in his mouth, and choked to deat...

A Bria of Godfrey resident with a diabetic foot ulcer that exposed bone received inconsistent wound care over months, wi...
10/30/2025

A Bria of Godfrey resident with a diabetic foot ulcer that exposed bone received inconsistent wound care over months, with staff repeatedly failing to implement hospital discharge orders, missing antibiotic doses, ignoring abnormal lab results showing serious infection, and leaving him without wound treatment for days at a time, resulting in multiple hospitalizations, sepsis and a surgeon warning he may lose his foot.

A Bria of Godfrey resident with a diabetic foot ulcer that exposed bone received inconsistent wound care over months, with staff repeatedly failing to implement hospital discharge orders, missing antibiotic doses, ignoring abnormal lab results showing serious infection, and leaving him without wound...

A Highlight Healthcare of Aurora resident with severe circulation problems had three toes amputated and returned to the ...
10/30/2025

A Highlight Healthcare of Aurora resident with severe circulation problems had three toes amputated and returned to the nursing home with orders for dressing changes every other day, but staff failed to change the dressing for five days, allowing the surgical wound to become infected and infested with maggots that required emergency surgery and critical care.

A Highlight Healthcare of Aurora resident with severe circulation problems had three toes amputated and returned to the nursing home with orders for dressing changes every other day, but staff failed to change the dressing for five days, allowing the surgical wound to become infected and infested wi...

A Friendship Manor Health Care resident developed a small wound that staff discovered but never properly treated, leadin...
10/30/2025

A Friendship Manor Health Care resident developed a small wound that staff discovered but never properly treated, leading to two large infected pressure ulcers that required surgical debridement at the bedside and antibiotic treatment for a serious bacterial infection.

A Friendship Manor Health Care resident developed a small wound that staff discovered but never properly treated, leading to two large infected pressure ulcers that required surgical debridement at the bedside and antibiotic treatment for a serious bacterial infection.

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