Grove Health & Rehab: Fall Causes Brain Bleed - IL
The patient, identified in inspection records only as R1, is a male resident who cannot reposition himself. That detail mattered. Every staff member interviewed after his fall said the same thing: you never leave a resident unattended during incontinent care, and if you have to step away for any reason, you lower the bed to the floor, roll the resident onto his back, cover him, and hand him the call light before you walk out.
The aide identified as V12 did none of that.
R1 ended up in the emergency department on November 10, 2025. The hospital record reviewed by inspectors described him as a trauma transfer. A CT scan taken at the referring facility was suspicious for a frontal contusion. The emergency department note read: "Patient was transferred here to be seen by neurosurgery. History mainly EMS patient has dementia. Minor head injury." The principal diagnosis on the emergency room visit record was intracranial hemorrhage.
Three separate staff members, interviewed independently on November 13, gave inspectors nearly identical accounts of what the aide should have done.
One CNA, V15, put it plainly: "When we are providing incontinent care, we are never ever supposed to leave the resident unattended ever, even for a second. If we need help, we are supposed to push the call light and/or put the resident's call light on and wait for help. If we can't wait, we are supposed to put the bed down all the way down to the floor, position the resident on their back, and give them their call light before we ever leave the room. R1 is not able to turn himself."
A second CNA, V16, said the same: "We are never to leave a resident unattended while providing incontinent care. If I did not bring the supplies I needed, then I would put the call light on and wait for help. If nobody came, then I would put the resident on their back, cover them up, lower the bed all the way to the floor and hand them the call light."
The facility's own corporate nurse, V17, reviewed what happened and did not hedge. "V12 should have put on the call light and waited for help," she told inspectors. "She should have never left the resident unattended."
A nurse practitioner interviewed on November 20, the day inspectors completed the complaint investigation, added the clinical reasoning behind the protocol. "During incontinent care if a staff member raised the bed, then I would expect the staff to lower the bed and place the resident on their back and or call for assistance before leaving the room," V26 said. "The resident should never be left with the bed raised unattended. I would not expect staff to leave the room with the bed up because it puts the resident at risk for falling out of the bed and they could sustain any injury from the fall."
He sustained exactly that injury.
The inspection cited the violation at a level of actual harm, meaning inspectors concluded the departure from standard care directly caused R1's injury, not that it might have or could have. He fell. He bled into his brain. He was loaded into an ambulance and transferred to a hospital with a neurosurgery department.
The facility's fall policy, dated July 1, 2023, defines an accident or incident as "any occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident." Leaving a man who cannot turn himself alone in a raised bed during incontinent care fits that definition without much debate.
What the policy does not explain is how a procedure that every interviewed staff member could recite from memory, down to the sequence of steps, was not followed when R1 needed it most.
He has dementia. He could not call out a clear account of what happened. He could not reposition himself away from the edge. He could not lower the bed. He was dependent, entirely, on the person who walked out of the room.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grove Health & Rehab Ctr, The from 2025-11-20 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 20, 2026 · Our methodology
GROVE HEALTH & REHAB CTR, THE in JACKSONVILLE, IL was cited for violations during a health inspection on November 20, 2025.
The patient, identified in inspection records only as R1, is a male resident who cannot reposition himself.
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.