Lakeside Health & Rehab: Unsafe Transfer Injuries - IL
Both were bruised and red. The left had a small skin tear on top. The right was, according to a nurse who examined her, the worse one. His wife was not complaining of pain. There was no swelling. But the marks were there, and they had not been there the night before.
The resident, identified in inspection records only as R6, required two staff members and a gait belt to be transferred safely. That morning, a nursing assistant had moved her alone.
The CNA, identified as V18, had already clocked out by the time the bruising was reported. She had turned in her notice before the shift began. When she walked out at 6:00 AM, her employment at Lakeside Health & Rehab Center was finished. The Director of Nurses told inspectors she informed facility leadership that V18 no longer worked there, because her employment had ended the moment she clocked out. V18 was marked ineligible for rehire. The investigation concluded she had likely transferred R6 by herself. V18 denied it.
That was the end of the facility's response.
The bruising was documented in a wound report filed at 7:00 AM on September 3rd. The report described red discoloration and bruising to both hands, with a skin tear on the top of the left hand. A licensed practical nurse, V20, told inspectors she had been notified about R6's wrists and hands, that the left had a skin tear, and that the right wrist appeared to be the worse injury. She said R6 was not complaining of pain and that she had passed the information up to the Director of Nurses and another supervisor.
Another CNA, V6, confirmed to inspectors on October 2nd what the care plan already said: R6 transfers with two staff members and a gait belt. This was not a judgment call. It was not a matter of interpretation. It was written into the resident's plan of care, and it had been the standard for her transfers.
The Director of Nurses, V2, laid out what she knew in an interview on October 2nd. She said she had conducted an investigation and determined that V18 transferred R6 by herself. She said V18's last shift had been a night shift, that V18 had already turned in her resignation before that shift, and that by the time the bruising was reported at 7:00 AM, V18 had been gone for an hour. The Director said she had notified a supervisor, identified as V16, that V18 was no longer an employee.
What the Director did not describe was any follow-up with R6's family.
V19, the resident's husband, sat with R6 every day. He told inspectors on September 29th, nearly four weeks after the September 3rd injury, that he had come in that morning to find R6's elbow bleeding a little. He said he had let the facility know. He assumed she had bumped it.
When an inspector asked whether he had concerns about abuse or his wife's safety, he said no. Then he added something.
About a month ago, he said, both of her wrists were bruised. It looked like she had been pulled. He said he was not sure what the facility had done about it.
That injury, the one to both wrists, would place it at approximately the same time as the September 3rd incident documented in the inspection report. Whether it was the same event described differently, a separate incident, or a detail the husband remembered imprecisely, the inspection report does not resolve. What it records is that the husband, who was present at the facility every single day, described seeing his wife's wrists bruised in a way that looked like she had been pulled, and that he did not know what had been done about it.
The facility's transfer policy, dated July 1, 2023, instructs staff to follow the resident's plan of care to ensure the use of proper transfer technique. It states that the transfer technique used for a resident will be evaluated and determined by a nurse or directed by therapy. The procedure begins with explaining to the resident what is about to happen and enlisting their help if they are able.
R6's plan of care required two people and a gait belt. On the morning of September 3rd, there was one.
The inspection was conducted on November 13, 2025, as a complaint investigation. The deficiency was cited under F0689, which addresses the obligation to protect residents from accidents. Inspectors assessed the level of harm as minimal harm or potential for actual harm, affecting a few residents.
The CNA who performed the transfer was gone before anyone documented the injuries. The investigation concluded she was likely responsible. She denied it. Her file was marked. She did not come back.
R6's husband kept coming back. Every day, he sat with her. He noticed the elbow in late September. He told the facility. He assumed she had bumped it. When the inspector asked him directly whether he was worried about his wife's safety, he said no.
Then he mentioned the wrists.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakeside Health & Rehab Center from 2025-11-13 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 22, 2026 · Our methodology
LAKESIDE HEALTH & REHAB CENTER in CARLINVILLE, IL was cited for violations during a health inspection on November 13, 2025.
The left had a small skin tear on top.
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.