Last June, an elderly stroke survivor residing at Chicago’s Lakeview Rehab and Nursing Center fell to the floor while being transferred by mechanical lift from his bed to a shower chair. The fall broke his leg in two places. A single nurse’s aide had texted her coworkers three times seeking help before attempting the lift. None responded. The nurse — in a clear violation of a requirement that two aides conduct any high-risk transfer — went ahead on her own.

It wasn’t an isolated incident at the 178-bed facility. Since the beginning of 2021, federal regulators fined Lakeview Rehab, which is run by privately-owned Infinity Healthcare Management, more than $250,000 for 10 serious violations, according to the government’s Nursing Home Compare website. The facility earned just one out of five stars for quality, the lowest possible rating.