Thrive of Lake County: Resident Fall During Solo Care - IL
The aide, identified in inspection records as V7, was working by herself on November 19, 2025, when she turned Resident 1 onto her right side to clean her. V7 was standing on the left side of the bed, behind the resident. The resident began scooting toward the edge.
V7 told the resident to stop. The resident kept moving.
"She told R1 to stop scooting because she was going to fall," inspectors recorded, "but R1 scooted a little and she could see R1's legs going over the edge of the bed."
V7 reached for the resident and couldn't get there in time. She grabbed her by the waist and eased her toward the floor. The resident ended up on the floor.
A second staff member, V6, heard V7 yelling for help from the room. By the time she got there, the resident was already down. V7 told her what happened: she had asked the resident to roll to her side, the legs went too far over, the resident started to slide, she grabbed the sheet, the sheet didn't stop anything, and she guided the resident down.
The Director of Nursing, V2, described the same sequence to inspectors that afternoon. During care, she said, the resident kept shifting herself. The aide asked her to stay still. The resident shifted again and started to slowly slide. The aide grabbed the sheet. The resident went to the floor anyway.
What V7 said next is the detail that matters most. She told inspectors that Resident 1 can help turn her own upper body, but needs assistance crossing her left leg over to complete the turn to her lower body. She said, plainly, that if there had been two people in the room, the fall would not have happened.
She also said that after the fall, she now uses two people whenever she turns Resident 1.
That's the sentence the inspection report leaves hanging. The aide knew, after the fact, that the job required two people. The question the report doesn't fully answer is what she knew before.
The facility's response focused on the resident. The Assistant Director of Nursing spoke with Resident 1 after the fall, updated her care plan, and added education on body position and alignment in bed. The plan, in other words, put the adjustment on the resident, a woman who inspectors noted needs help moving her own lower body.
Federal inspectors cited the facility under F0689, the tag covering accidents and supervision, finding the violation caused minimal harm or potential for actual harm. The citation covered a small number of residents.
That classification, minimal harm, reflects the regulatory framework's language, not necessarily what it felt like to be a woman sliding off a bed while a single aide grabbed at a sheet. The resident ended up on the floor of her room. Another staff member had to come running when she heard shouting.
The care plan was updated. The aide changed how she works with this resident. The facility, at least on paper, moved on.
What the record doesn't show is whether anyone asked, before November 19th, whether turning this particular resident, a woman who needs help with her lower body, was a one-person job.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Thrive of Lake County from 2025-11-19 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: August 30, 2026 · Our methodology
THRIVE OF LAKE COUNTY in MUNDELEIN, IL was cited for violations during a health inspection on November 19, 2025.
The aide, identified in inspection records as V7, was working by herself on November 19, 2025, when she turned Resident 1 onto her right side to clean her.
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.