Nursing Home Spotlight: Lexington of Elmhurst


On November 17, 2009, the Illinois Department of Public Health fined the Lexington of Elmhurst nursing home $25,000 for fourth quarter Nursing Home Care Act violations relating to the area of nursing. The nursing home’s failures resulted in several residents suffering from preventable injuries. Lexington of Elmhurst is a large, 145-bed, one-star (much below average) Medicare rated nursing home facility located in Elmhurst, IL.

Nursing Home Spotlight: Lexington of ElmhurstA September 2009 survey conducted by the Illinois Department of Public Health (IDPH) revealed numerous deficiencies including failure to implement measures to reduce the risk of falls for four of fourteen residents in the sample who were identified to be at risk for falls. These included failures to:

  • Supervise a female resident who had been identified as a wanderer with an unsteady gait, analyze and evaluate the cause of her multiple falls and injuries,
  • Implement a care plan to assist and supervise her,
  • Develop individualized interventions based on her needs,
  • Ensure that staff are adequately trained to transfer three other residents and deal with resident behaviors and develop care plans to prevent incidents and accidents, and
  • Ensure that the nursing home has a system in place to ensure that these incidents did not involve abuse.

Elderly nursing home residents are particularly susceptible to dangerous falls because of reduced mobility, lack of balance, poor eyesight, weakness, weak bones, and other underlying conditions. As you age, your bones weaken and break more easily.

So, even minor falls can pose a major risk for the elderly. (See “Nursing Home Patients with Osteopenia May Suffer More Severe Injuries During Falls” and “Osteoporosis Puts Nursing Home Patients at a Heightened Risk for Fractures Related to Falls”). Therefore, nursing homes must take extra precautions to reduce the risk of dangerous falls.

A female resident suffered from multiple falls and injuries while in residence at Lexington of Elmhurst because the facility failed to take necessary preventative measures despite being aware that she had an unsteady gait, did not use assistive device to walk, held onto rails in hallway, had impaired safety awareness, and also had periods of agitation and wandering.

The facility’s only preventative measures included supervision / assistance when walking, using caution when transporting resident, and providing close supervision when resident was agitated or anxious. However, the facility failed to implement the measures that they did have in place, resulting in the resident suffering from numerous falls and injuries.

This resident’s care plan noted numerous incidents and falls:

  • 11/10/08 – resident noted on floor in hallway
  • 11/11/08 – noted on floor in her room
  • 12/14/08 – noted on floor in dining room
  • 1/10/09 – remains at risk for falls
  • 4/04/09 – assisted on the floor
  • 4/08/09 – noted on the floor
  • 4/16/09 – two falls within the last two weeks (confused with periods of agitation, wandering, unsteady gait, may be difficult to direct, impaired safety awareness)
  • 5/09/09 – slid out of wheelchair

On April 13, 2009, nursing home staff noticed that the resident had bruising on her upper arm and shoulder with swelling, pain, and inability to lift hand. X-rays revealed that the resident was suffering from a fracture of the upper arm/shoulder. Despite noting a fall on April 8, Nineteen days later, her shoulder fracture worsened into a comminuted fracture (or multi-fragmentary fracture), where the bone actually splits into multiple pieces.

A second resident was first admitted to the nursing home because of a head injury caused by a fall at home. He was later readmitted to the facility for an elbow fracture that occurred as a result of another fall at home. On August 7, 2009, the resident was found lying on the floor calling for help. He suffered from a fracture to the left thigh bone (femur) and abrasion to the right side of the head and right knee.

There was no analysis/investigation of how this fail occurred because the fall committee did perform an evaluation since they were only aware of one previous fall. However, the resident had suffered from two previous documented falls. While the facility did in fact document two prior falls, the nursing home facility failed to analyze/investigate the resident’s injuries, which means that no additional preventative measures were put in place to prevent future injuries and his plan of care was never updated. This kept the resident at risk for future possible falls, which could lead to more severe injuries.

Yet another resident suffered from two fall incidents and also suffered from a large bruise of unknown origin. One fall occurred in the shower, when the resident was actually being washed by a Certified Nurse Aide (CNA). The resident sustained a two inch laceration to the back of head. The facility again failed to analyze the falls or the bruise of unknown origin, which left the resident at risk for future falls.

Lexington of Elmhurst failed to provide the best possible care for its residents when it failed to investigate the falls of multiple residents. The facility did not implement any additional precautions to reduce these residents’ risk of dangerous falls, which put their safety and well-being in danger. These failures raise doubts about the level of care that other residents are receiving.

If you or a family member suffered from an injury while a resident at Lexington of Elmhurst, you may be entitled to compensation, especially when the facility failed to take steps to prevent easily preventable injuries.


IDPH: Lexington of Elmhurst – 4th Quarter Violations

Medicare: Nursing Home Compare – Lexington of Elmhurst

Nursing Home Abuse Blog: Nursing Home Falls

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Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric