St Clara's Rehab: Wheelchair Unsecured in Transport - IL
He had just received his license to transport residents. He had been trained on how to secure wheelchairs in the van. But when he loaded the resident, he only locked the wheelchair wheels and left it at that. The facility, he reasoned, was only a block away.
At the stop sign leaving the hospital parking lot, he hit the gas. The resident rolled backward.
Federal inspectors cited St. Clara's Rehab & Senior Care in Lincoln for that incident following a complaint inspection completed October 15, 2025. The citation carries a finding of actual harm.
The nurse, identified in inspection records as V5, described what happened in his own words during an interview with inspectors that morning. "It was around 1:30am in the morning; figured it was just a block away to the facility," he told investigators. "I stopped at the stop sign out of the hospital parking lot; stepped on gas and (R1) rolled backwards."
He said he had been trained on how to secure wheelchairs. He did not do it.
V5 told inspectors that the day of the accident was the first time he had ever driven the facility van to transport residents. He had just gotten the license to do it. He knew the full securement procedure. He chose not to use it because of the distance.
One block. One stop sign. One resident rolling backward in the dark.
After the accident, the facility's administrator, identified as V1, called V5. According to V1's account to inspectors, V5 said he was getting too old for all the new technology and told the administrator he was putting in his resignation immediately. V5 confirmed that account. "I felt so bad about this," he told inspectors. "I resigned the next day."
The administrator told inspectors that the resident's power of attorney was contacted after the accident. "Both myself and (V3) agreed that the accident could have been avoided," V1 said.
That agreement, offered plainly and without apparent dispute, is the clearest summary of what the inspection record shows: a trained driver, on his first trip, made a choice that hurt someone, and everyone involved knew it didn't have to happen.
The inspection record does not describe the extent of the resident's injuries beyond the finding of actual harm. It does not say whether the resident required further treatment, or what the ride back to the facility looked like after the chair rolled.
What it does say is that V5 knew how to properly restrain a wheelchair in the van. The training had happened. The knowledge was there. At 1:30 in the morning, one block from the facility, he decided it wasn't necessary.
The administrator confirmed that V5 was responsible for securing residents in the van. That responsibility, and what V5 did with it in the early hours of that morning, is what federal inspectors came to Lincoln to document.
V5 is no longer at the facility. He resigned the day after the accident. The resident whose wheelchair rolled backward when the van pulled away from the stop sign remains identified in federal records only as R1.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Clara's Rehab & Senior Care from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
ST CLARA'S REHAB & SENIOR CARE in LINCOLN, IL was cited for violations during a health inspection on October 15, 2025.
He had just received his license to transport residents.
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.