Alden Estates of Orland Park: Lift Fall Sends Resident to ER - IL
The incident happened on April 23, 2026. The hospital record documents it plainly: the resident, identified in inspection records as R2, came to the emergency department after falling out of a mechanical lift at the facility. She said she landed on her right side and hit her head. She denied losing consciousness.
What the hospital record also notes is that before staff placed R2 into the mechanical lift, EMS reported she had been given Ativan.
The facility's own administrator described what happened next. R2 was lifted from her chair and positioned over her bed. A certified nursing assistant, identified as V17, was operating the mechanical lift. A second CNA, identified as V14, had walked to the other side of the bed to spot R2 during the transfer. Just as V14 was moving into position, R2 began flailing, throwing her arms and legs, yelling that she wanted water. V17 tried to grab the lift to keep it upright. It wasn't enough. R2's weight carried her toward the foot of the bed. The back leg of the mechanical lift caught the head of the bed and lifted it. R2 landed at the foot of the bed, on the mattress, and the force of her landing combined with the lift leg raising the bed frame created a seesaw effect. R2 rolled off the foot of the bed and onto the floor.
The mattress, the administrator noted, broke her fall.
R2 had a care plan for fall risk going back to October 2022, tied to cognitive and functional deficits. That care plan was updated in April 2026, less than a month before the fall, to include a specific intervention: assess the resident for anxiety and agitation before any transfer.
There is no indication in the inspection report that assessment happened before staff put R2 into the lift on April 23.
The CNA who operated the lift offered a detail that cuts to the center of the problem. In describing why the transfer proceeded despite R2's agitation, the inspection report records this explanation: "For what I know she was not agitated or potential for actual harm enough for the transfer not to happen. If we waited for her, she would not have been transferred because she screamed a lot."
That reasoning, documented in a federal inspection report, is the judgment that preceded a woman being sent to the emergency room.
The inspection was conducted on May 22, 2026, following a complaint. Inspectors cited the facility for failing to provide adequate supervision and assistive devices to prevent accidents, a deficiency affecting a small number of residents and assessed at the level of minimal harm or potential for actual harm.
R2's care plan had flagged her as someone who required a specific pre-transfer check. The update to that plan in late April 2026 suggests staff or clinicians already understood that her agitation during transfers was a known, documented risk. The Ativan administered before the lift transfer suggests someone recognized that risk on the day it happened. And still, when the lift began to tip and R2 went over the foot of the bed and onto the floor, there was only one CNA in position to spot her, and that CNA had not yet finished walking to the other side of the bed.
She went to the hospital complaining of pain on the right side of her head and back.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Estates of Orland Park from 2026-05-22 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.
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Last verified: October 31, 2026 · Our methodology
ALDEN ESTATES OF ORLAND PARK in ORLAND PARK, IL was cited for violations during a health inspection on May 22, 2026.
The incident happened on April 23, 2026.
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.