Sunrise Skilled Nur & Rehab: Fall Death Violation - IL
The resident, identified in inspection records only as R2, was a hospice patient at Sunrise Skilled Nursing and Rehabilitation when she fell and fractured her right hip. She died approximately one week later. Her family member, identified as V5, told inspectors he had been in contact with hospice services about whether to keep her under hospice care or pursue hospital treatment and additional medical intervention. The plan, as he understood it, was to wait for the x-ray results, see how she was doing, and decide from there.
Nobody gave him that conversation.
Federal inspectors cited Sunrise Skilled Nursing and Rehabilitation on October 14, 2025, following a complaint investigation. The citation, tagged F0689 and carrying a finding of actual harm, centered on the facility's fall prevention program and what happened, or didn't happen, after R2 hit the ground.
V5 told inspectors plainly: he was never given the opportunity to make a choice about her care. R2 expired approximately one week after the fall. The window closed without him.
The hospice physician, identified as V18, said he believes he was notified of the x-ray results but could not specifically recall whether he personally reviewed them. The results, he said, may have just been sent to the fax machine.
That detail sits at the center of what went wrong. A woman under hospice care fell and fractured her hip. The physician responsible for her care under that hospice arrangement could not say with certainty whether he had seen the imaging that confirmed the fracture. The x-rays may have arrived at a fax machine. Whether anyone pulled them off that machine and put them in front of the doctor, the record does not confirm.
V18 described the general standard for fractures in hospice patients: pain management is typically the treatment of choice. If the fracture is unstable, or if pain cannot be controlled with medication, other options might be considered. But that determination, he said, requires a conversation between the resident and their representative and the hospice team together. It is not a unilateral clinical call. It belongs to the family.
V5 never had that conversation.
V18 also addressed the question of embolism. He noted that decreased mobility in a hospice resident can lead to clot formation even without a fracture, though he acknowledged a fracture increases the risk. More extensive testing for emboli, he said, would not generally be pursued under hospice care. He stated that to his knowledge the facility responded appropriately, providing effective pain management, and that R2 remained under hospice care until her death.
That assessment, offered by the physician who could not confirm he had personally reviewed her x-rays, is now part of a federal inspection record that found actual harm.
The facility's fall prevention policy, dated prior to the inspection, states that its purpose is to provide guidance to staff on preventing falls and minimizing complications when falls occur. Staff are supposed to identify interventions specific to each resident's risks and causes, both to prevent falls and to reduce harm when they happen. R2 fell anyway. What followed her fall is what the inspectors found deficient.
The citation does not specify what interventions were or were not in place before R2 fell. It does not describe the circumstances of the fall itself, what she was doing, where she was, who was nearby, or how long it took staff to recognize she was injured. What the record captures is the aftermath: a fractured hip, a family member waiting for a phone call that never came, a physician uncertain whether he read the imaging, and a woman dead within a week.
V5's account is the most precise piece of the record. He had already worked through his own thinking. Comfort care. Pain control. That was likely where he would have landed. He had been in contact with hospice about the options. He understood what the choice looked like. He was ready to be part of it.
He described it to inspectors not as an accusation but as a fact: he was never given the opportunity.
The hospice physician's account, by contrast, carries more uncertainty. He believes he was notified. He cannot specifically recall. The fax machine. The language in the inspection record is careful and clinical, but the picture it draws is of a communication system that may have delivered critical information to a piece of office equipment rather than to the hands of the doctor responsible for deciding what came next.
There is no indication in the inspection record that anyone at the facility identified this gap while R2 was still alive.
The fall prevention policy's stated goal is to minimize complications from falling. A hip fracture in an elderly hospice patient is a serious complication. The clinical literature on hip fractures in this population is unambiguous about the risk: immobility increases the likelihood of deep vein thrombosis and pulmonary embolism. V18 acknowledged as much, noting that even without a fracture, a hospice resident's reduced mobility creates that risk, and that a fracture raises it further.
Whether any of that contributed to R2's death in the week after her fall is not answered in the inspection record. What is answered is that her family member did not get to participate in the decisions that might have mattered.
The citation carries a finding of actual harm, meaning inspectors determined that real injury, not just the potential for it, resulted from the deficiency identified. R2 is dead. Her family member is on record saying he was never given a chance to weigh in on what her final days looked like.
V5 told inspectors that had he known about the hip fracture, his goal most likely would have been for R2 to remain comfortable and receive pain control. He used the phrase "most likely." He was not certain, because he never got to sit with the information and make the call. The facility's fall prevention program, whatever it promised on paper about minimizing complications, did not include making sure this man knew what had happened to the woman he was responsible for, in time to do anything about it.
He found out after she was gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunrise Skilled Nur & Rehab from 2025-10-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
SUNRISE SKILLED NUR & REHAB in VIRDEN, IL was cited for immediate jeopardy violations during a health inspection on October 14, 2025.
She died approximately one week later.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.