Illinois Nursing Home Violations (2nd Quarter 2017)

Quarterly Illinois Report April to June 2017By Illinois state law, nursing facilities must remain in compliance with care requirements as defined by Medicare, Medicaid, and the state. These Annual Surveys and Certification processes and unannounced investigations help determine if the facility has violated any one of the 180+ nursing home regulations enforced by federal and state law.

When a deficiency is found, it must be promptly addressed and corrected. In some incidents, the facility will receive a fine for serious violations that are known to jeopardize the health and well-being of the resident or cause a severe injury or death.

Please find the report for the Second Quarter here.

If you believe your loved one was abused or mistreated at a skillled nursing facility in Illinois, we invite you to contact our office for a free case review. Rosenfeld Injury Lawyers LLC remains committed to protecting the rights of nursing home patients across Illinois. Read more about our nursing home practice here.


The following Illinois nursing facilities received monetary fines that were doubled from $12,500-$25,000 and upwards to $50,000 due to the seriousness of substandard care. These include:

Addolorata Villa
555 McHenry Road
Wheeling, IL 60090, IL 60090

Due to the seriousness of personal injury of the resident caused by the violation, the nursing home received a fine of $25,000.00

In a summary statement of deficiencies dated April 7, 2017, the state surveyor noted after concluding an incident investigation that the facility failed to “provide supervision while the resident was on the toilet and failed to follow the care plan fall interventions for [the resident that resulted in the resident] sustaining fractures of the tibia and fibula leading up to hospitalization.”

The incident involved a 90-year-old female whose February 3, 2016, Risk Screen Tool indicated a score of 16 representing a significantly high risk of falling. The resident’s February 20, 2017, Care Plan for Fall Intervention did note that the staff is to be reminded that the resident needs “total supervision with toileting… instructions were provided at the start of the shift and as needed.”

The resident’s initial March 14, 2017, Incident Report that was forwarded to the State Agency stated that the previous day at approximately 7:15 PM “after dinner the assigned Certified Nursing Assistant toileted the resident… after a few minutes, the resident was noted sitting on the bathroom floor facing the toilet.” The documentation states that the resident was sent to the emergency room “for evaluation and treatment and admitted for tibia fracture.”

The Incident Report stated that the CNA “observed another resident needed assistance immediately while with this resident” was on the toilet and stepped out to offer help and upon returning “observed the [injured] resident on the floor.” The state investigator noted the facility failed to follow their own Falls/Clinical Protocol policy and fined the nursing home $25,000.

Covenant Healthcare Center – Batavia
831 North Batavia Avenue
Batavia, IL 60510

Because of the severity of the violations that led to the resident’s hospitalization and death, the nursing home received a fine of $25,000.00.

In a summary statement of deficiencies dated May 11, 2017, the State surveyor noted that this facility failed to “ensure the resident was safely transferred by staff in accordance with facility policy.” The nursing home also “failed to ensure residents were monitored during toileting and failed to implement safety precautions documented in the resident record to prevent falls.” The failure by the nursing staff resulted in the resident “sustaining bilateral femur fractures, being admitted to hospice and expiring on May 11, 2017.”

The facility’s May 7, 2017, Occurrence Report shows that at 5:00 AM, a staff registered nurse “called the supervisor to report that the resident had sustained a fall [… and was] lying on her back with a sling under her arm.” The resident was fighting and was combative with the lone CNA who was assisting her just prior to the incident where she “slid off and fell on the floor on her back.”

The assisting CNA told the investigator that “the only mistake I made was transferring her by myself. I used the mechanical lift and assumed I put her in the chair, I moved the mechanical lift and she slid out of the chair.” The Director of Nursing stated that “the facility’s policy is that all mechanical lift transfer should be done with two staff members present.

Du Page Care Center
400 N. County Farm Road
Wheaton, IL 60187

Due to repeated occurrences of serious falls that led to a resident’s injury, the nursing home was fined $25,000.00.

In a summary statement of deficiencies dated March 24, 2017, the State surveyors noted that the facility had failed to “ensure staff monitored residents to prevent sustaining injuries when staff was transferring residents who are dependent on the staff for their safe transfer from bed to chair and/or from chair to bed. The facility also failed to implement interventions per their plan of care” that resulted in three residents being injured with serious injuries while being transferred. These incidents occurred within eight days of each other.

As a result of the failure by the nursing staff, a resident “sustained a laceration to her scalp and fractured left proximal tibia … and fibular neck when staff transferred her on March 13, 2017, from the bed to a motorized chair with total mechanical lift.”

In a separate incident, another resident “sustained a left intertrochanteric hip fracture when staff transferred him on March 12, 2017, from the bed to the wheelchair with a ‘sit to stand’ mechanical lift.” A third resident suffered injuries after sustaining a “left fourth toe fracture when the staff transferred her on March 20, 2017, with a total mechanical lift from the wheelchair to the bed.”

The Fall Risk Care Plan records dated January 24, 2017, revealed a fourth resident who “fell on the floor 14 times [including on] December 8, 9, 18, 20, 21, 23, 2016; January 1, 15, 31, 2017, and again on March 8, 2017. The facility was fined $25,000 for multiple violations of the Illinois Nursing Home Care Act.

Harmony Nursing & Rehabilitation Center
3919 West Forest Avenue
Chicago, IL 60625

Due to the seriousness of substandard care that led to a resident suffering extensive injury, the nursing home was fined $25,000.00.

in a summary statement of deficiencies dated March 2, 2017, the state investigator noted that this facility failed to “conduct a follow-up assessment of the change of eye condition” and a failure to “follow the facility’s skin assessment policy and conduct a skin assessment every other day for [a resident].” Because of these failures, the resident’s eye swelling and redness worsened and [the resident] was sent to the hospital for evaluation.”

The resident “was admitted and treated for conjunctival infection. During the emergency room examination, [the resident] was assessed with two unidentified deep tissue injuries to the inner thigh area.” The emergency room records dated February 17, 2017, documents of the resident “had a conjunctival infection, lid inflammation, and exudate (fluid) in both eyes. An ostomy with erosion and redness of the mucosal surface with leaking of enteral contents. Public examination revealed redness and information to the vaginal mucosa tissue.”

The hospital’s Wound Care Consultant noted on February 17, 2017, that the “female genitalia with mirror image wound on the bilateral inner thigh that is covered with eschar (dead tissue) and painful to palpitation [touch].” The Director of Nursing stated to the investigator that “we might have just missed the wound on [the resident’s] thighs because we were so focused on the facial rash.”

Hope Creek Care Center
4343 Kennedy Drive
East Moline, IL 61244

Due to the seriousness of the failure of the nursing staff that led to a resident requiring a leg amputation, the facility was fined $25,000.00.

in a summary statement of deficiencies dated March 2, 2017, the state investigator noted that the facility had failed to “maintain a safe mechanical lift transfer for [one resident]. This failure contributed to a fall [resulting in] a right supracondylar femur fracture which required a right above the knee amputation.” This type of fracture causes a break of the thigh bone at the knee.

The state investigator noted that the facility’s January 19, 2017, Care Plan for the resident read “Falls: The resident has had an actual fall where she slid from her mechanical lift while being lifted to the toilet on December 27, 2016 (while not a resident).” The resident’s Care Plan also documents that the resident will be transferred with “one mechanical transfer, using mechanical lift an extra-large full-body sling.”

The January 26, 2017, Emergency Department Physician’s Notes states that the resident arrived at the facility after a fall and “is a resident of the local nursing home. The granddaughter states that [the resident] was at the bedside when she was dropped. Family reports the resident was being lifted with a mechanical lift by a nursing staff member when the strap of the mechanical lift came undone and the patient fell straight to the floor. The family states that her right leg hit the mechanical lift during the fall and then hit the floor [and that the resident] is complaining of right leg pain.”

The facility’s Restorative Director stated that “it is the responsibility of the Certified Nursing Assistants to be inspecting the mechanical lift, including the metal hooks/with quick attach to ensure that the clip is close to the hook. There is a potential that the loop on the sling can go underneath the clip and detach from the hook causing the resident to fall. It is possible that that could have been the problem with the resident’s mechanical lift.”

Lexington Health Care Center Lombard
2100 South Finley Road
Lombard, IL 60148

Due to the seriousness of the violation by the nursing staff that resulted in a severe femur fracture of a resident, the facility was fined $25,000.00

In a summary statement of deficiencies dated February 17, 2017, the state investigator, after concluding a survey on licensure violations noted that the facility had failed to “ensure a resident was safely transferred by staff. This failure resulted in the traumatic fall causing a displaced supracondylar femur fracture.”

A review of the resident’’s Progress Notes states that the resident “requires significant ADL [activities of daily living] assistance with bathing, dressing and transfer activities. The resident has previously fallen with hip fracture, has advanced dementia, gait instability and is on fall precautions.” The resident’s January 31, 2017, Fall Care Plan states that the resident has “history of falls, receiving psychotropic medications, impaired mobility, incontinence, confusion, forgetful and with the diagnosis of dementia.”

The facility’s Incident Report Investigation dated February 6, 2017 identified that on that date the resident “slid off the chair during a transfer from a wheelchair to a shower chair [while] being transferred by only one staff member without the use of the gait belt or the use of a ‘sit to stand’ lift as care planned.” A Registered Nurse stated that the Certified Nursing Assistant “was trying to transfer [the resident] from the wheelchair to the shower chair by herself and without the use of the gait belt on the resident.”

The nurse stated that “the resident was a two-person assist with a ‘sit to stand’ lift during transfer activities [… and] would have difficulty standing without physical assistance of staff.”

Lydia Healthcare
13901 South Lydia
Robbins, IL 60472

Due to the repeated substandard care provided by the nursing staff that led to a resident swallowing foreign objects requiring surgical intervention, the facility was fined of $25,000.00.

in a summary statement of deficiencies dated May 16, 2017, the State surveyor noted after conducting a complaint investigation over licensure violations that the facility “failed to provide effective supervision and carry out a plan of care to prevent subsequent PICA behaviors (eating disorder related to persistent ingestion of nonnutritive substances or items) for two [residents at the facility]. The failure resulted in [one resident] continuing to ingest foreign objects with potential for further foreign object removal surgery.”

Multiple medical records from 2015 through 2016 noted repeated times that the resident attempted to swallow foreign objects. The resident’s December 20, 2016, Hospital Records document that foreign options were found in the abdomen of the resident upon admission stating that the resident “will have surgery on December 27, 2016, related to four foreign objects in [the resident’s] abdominal cavity.”

The resident’s April 5, 2017, Progress Notes documents that the resident’s room was searched … and staff observed [the resident’s] call light bulb was missing.”

An interview conducted with the facility’s Nurse Practitioner on the afternoon of May 11, 2016, revealed that “I would expect staff to move the resident close to the nursing station for closer monitoring with routine checks. There are serious medical issues that can occur from ingesting batteries and light bulbs, such as gastrointestinal tears or bowel obstructions which would require surgical interventions.” The resident’s April 7, 2017, CT (Computed Tomography) scan revealed “impressions – there are multiple foreign bodies in [the resident’s] bowel. Approximately six items are identified.”

Mado Healthcare – Douglas Park
1550 South Albany
Chicago, IL 60623

Due to a physical assault by one resident that caused the death of another and the lack of action taken by the nursing staff and administrator, the facility was fined $50,000.00.

in a summary statement of deficiencies dated May 3, 2017, the state investigator noted multiple severe violations of the Illinois Nursing Home Care Act that involved a failure to “implement interventions to address a history of criminal assault for [a resident].” The facility also failed to “intervene and protect [another resident] from physical assault by [the abusive resident]. These failures resulted in the abusive resident “becoming enraged, throwing [another resident] from a chair, hitting [that resident] with the chair and repeatedly stomping on [that resident’s] head with his foot as staff stood by.” The injured resident “was admitted to the hospital with a head injury and subsequently died of complications from cerebral (brain) injuries.”

The state investigator reviewed the facility’s January 2015 Client Background Checks and Identified Offender Policy that states in part that:

“The facility is responsible for taking necessary steps to ensure the safety of clients while the results of the background check or other identified offender report and recommendations are pending.”

The resident’s May 17, 2016, the pre-admittance documentation states that the resident “has had anger issues since [they were] a child.” The resident “was involved in an aggravated battery received a two-year sentence [and while incarcerated] got into frequent fights and altercations with both the prison guards and other prisoners, thus extending [their] incarceration from two years to eight years” which was served completely.

However, the resident’s June 6, 2016, Care Plan “does not have any documentation about [the aggressive resident] being a possible identified offender, history of aggravated assault with battery, and does not include any interventions related to aggression or assaultive behavior.” The injured resident’s Death Certificate states that the cause of death was: “Complications of Remote Cerebral Injuries, Blunt Force Trauma to the head.”

As of April 27, 2017, the aggressive assaulting resident remains in jail. The state of Illinois fined the nursing home $50,000 as a “Type AA” violation due to its severity where the failure led to the death of another resident.

Manorcare of Westmont
512 East Ogden Avenue
Westmont, IL 6055

Because the violations of the Illinois Nursing Home Care Act were serious, the nursing home was fined of $25,000.00.

In a summary statement of deficiencies dated February 9, 2017, the state investigator noted during an incident report investigation occurring on January 27, 2017, that the facility failed to “follow physician’s orders and failed to ensure residents remain free of significant medication errors.” The failures by the nursing staff resulted in the resident “receiving Coumadin 2 mg for 12 days without a physician’s orders and was admitted to the hospital for gastrointestinal bleeding.”

The resident’s January 26, 2017 Physician Progress Notes described the resident as “dazed and nonverbal.” The January 27, 2017, State Report of Patient Incident described the incident as “Coumadin given in error, the resident sent to the hospital.” The hospital diagnosed the resident with gastrointestinal bleeding (likely lower gastrointestinal bleed) “likely lower gastrointestinal bleed; anemia, likely secondary to gastrointestinal bleed and [the resident] was on anticoagulation for unknown reasons”.

Meadows Mennonite Home
24588 Church Street
Chenoa, IL 61726

Because of the abusive nature of posting humiliating and disturbing unauthorized pictures and videos of residents at the facility, the nursing home was fined $25,000.00.

in a summary statement of deficiencies dated March 28, 2017, the state investigator after concluding a complaint investigation noted that the facility had failed to “protect six cognitively impaired residents who live in a secure dementia unit for mental abuse perpetrated by one staff member who took unauthorized pictures and a video.” The state investigator noted that “these pictures were of residents during toileting, bathing, in bed, and in wheelchairs and included partial nudity.”

It was also noted that the “facility staff had failed to follow facility policy and report known unauthorized pictures and video of these resident since April 2016.” The pictures of four residents “were posted on a social media website. All the pictures and the video were stored on [the staff member’s] personal cell phone. As a result, these residents were unable to express themselves, suffered public humiliation and dehumanization.”

The facility’s administrator on the morning of March 9, 2017, received notice that unauthorized pictures were on social media. The police arrived at the facility at “approximately 8:15 p.m. Additional management [including the] Human Resource Director and Executive Director [were also notified]. Families were contacted by management staff. Social media site was contacted by the administrator who requested removal of pictures from all social media sites. The Senior Sales Marketing Director removed the pictures from the facility social media website and blocked further unauthorized usage of the facility’s webpage on social media.”

Midway Neurological/Rehabilitation Center
8540 South Harlem Avenue
Bridgeview, IL 60455

Due to the severity of injuries and the seriousness of nursing home care act violations by eight staff members at the nursing home, the facility was fined $25,000.00.

in a summary statement of deficiencies dated March 15, 2017, final observations were made by the State surveyor during a review of licensure violations who noted that the facility failed to “prevent a resident from entering a restricted room containing a linen chute to the facility laundering area. As a result [the resident] entered the room and fell down the linen chute five stories into the laundry bin in the facility’s laundry room.” The resident “sustained fractured bones in both legs and spine and required hospitalization and surgery.”

The state investigator reviewed the facility’s February 22, 2017, Incident Report revealed that the resident “fell and sustained a laceration to bilateral elbow and swelling of bilateral ankles. The report showed that [the resident] was unable to give any information [… And that the resident] was confused and disoriented. The report does not give the location of the resident’s fall.”

In the final report sent to the Illinois Department of Health dated February 26, 2017, it was revealed that the resident “was sent to the hospital with hip and ankle fractures.” The facility investigation identified that the resident had “fallen down the laundry chute from the fifth floor.” Videotapes revealed that the resident had gone into the fifth-floor laundry room because “the door did not latch at that moment. The investigation showed that based on the facility findings of the investigation, the staff members in charge were suspended without pay for two days.”

Morton Terrace H & R Centre
191 East Queenwood Road
Morton, IL 61550

Due to the neglectful actions of the nursing staff in providing immediate medical treatment that was required to ensure a resident’s health and well-being, the facility was fined $25,000.00.

in a summary statement of deficiencies dated April 18, 2017, the state investigator noted that the nursing home had failed to “provide prompt medical care to prevent worsening of a right lower extremity obstruction for [a resident that resulted in the resident] failing to immediately receive treatment to relieve [their] right leg from worsening ischemia (lack of blood flow), which contributed to [the resident’s] death.”

The investigator reviewed the resident’s April 6, 2017, Nurses Notes that were documented by a licensed practical nurse who stated that “a CNA (Certified Nursing Assistant) alerted this nurse to the resident’s room. Upon observation, the resident’s right foot was purple in color, cold to touch, and had no pedal pulses present. The right lower extremity becomes colder to touch approximately 1 cm below the knee.” Even though the resident was sent to the emergency room for evaluation and treatment, their physician was not notified.

The hospital “recommended amputation of the right lower extremity; however, the family wants to focus on comfort.” In addition, it was revealed that the resident’s “Nurse’s Notes do not include any other nursing assessments or documentation of the condition of [the resident’s] leg between April 6, 2017, 2:50 PM and April 7, 2017, at 10:00 PM.” The resident’s 5:09 AM April 17, 2017, Clinical Entry stated that the resident “passed away 4:00 AM due to medical reasons.”

The resident’s surgeon stated that “the lack of, and delay in treatment of getting the Dopplers and getting the resident treatment [at the nursing home] when they (the facility) know there is an obstruction of the right femoral artery was neglectful.”

Mulberry Manor
612 East Davie Street, Box 88
Anna, IL 62906

Due to the multiple violations of the Nursing Home Care Act involving peer-to-peer abuse, lack of supervision, and lack of providing a safe environment, the facility was fined $25,000.00.

in a summary statement of deficiencies dated February 16, 2017, the state investigator noted during an annual licensure survey that the facility had failed (to provide necessary operating directions over the facility which ensures that policy and procedures are developed and implemented by the facility to protect the health and safety of [13 residents].” The failure by the administration and the nursing staff had the “potential to affect the remaining 31 individuals at the facility when they failed to provide necessary oversight.”

These violations included failure to “ensure the provision of supervision necessary to prevent elopement.” As a result, an elopement occurred on August 23, 2016. By January 23, 2016, “the door leading to the courtyard is [still] not alarmed and the gate [still] does not have a security system installed to alert staff of any individual’s attempt to elope.”

Another incident involving PICA (swallowing foreign objects) occurred in January 2017 involving individual “who is not constantly supervised while outside smoking and has documented incidents of ingesting quarters and metal rings attached to soda cans when unsupervised.”

The facility also failed to “thoroughly investigate peer-to-peer abuse and injuries of unknown origin, report these incidents to the Illinois Department of Public Health, and take corrective actions to prevent further potential incidents of peer-to-peer abuse.

Pleasant Hill Village
1010 West North Street
Girard, IL 62640

Because of the seriousness of the nursing home violations that could have been the potential cause of a resident’s death, the facility was fined $25,000.00.

In a summary statement of deficiencies dated April 13, 2017, the state investigator noted during the conclusion of a complaint investigation that the facility had failed to “assess, implement and monitor residents for safe positioning to prevent accidents.” The failure resulted in one resident’s “improper positioning which could have contributed to her death.”

A Certified Nursing Assistant (CNA) stated that on the evening that the resident passed away that they had “walked into the resident’s room to check and change her. When I enter the room, I found [the resident] lying on her left side with her face in a pillow. I turned her onto her back, check for a pulse, [and] called the nurse to help. The pillow had what I can describe as yellow/clear mucus on it.” That CNA had stated that “you could tell her face had been in that pillow for some time [… and] she noticed [the resident’s] nose was pushed all the way to the right [stating that the resident’s] face was smashed in from being in the pillow.”

Another CNA stated that the resident “had limited movement and needed staff assistance for turning and positioning.” The resident’s Death Certificate signed by the medical doctor on April 3, 2017, documents the cause of death as “multi organ failure.” The certificate “further documents that the “coroner was not notified.”

Pleasant View Rehabilitation & Healthcare Center
500 North Jackson Street
Morrison, IL 61270

Because the nursing facility failed to provide two staff members to transfer a resident when showering that led to bilateral femur fractures, the facility was fined $25,000.00

In a summary statement of deficiencies dated February 20, 2017, the state investigator noted that the facility failed to “provide care in a safe manner to prevent a resident sliding out of a shower chair. This failure resulted in the resident having bilateral femur fractures requiring surgical interventions.”

Documentation from the facility noted that on February 16, 2017, a Certified Nursing Assistant (CNA) gave the resident “a shower [while] standing in front of [the resident] trying to button her shirt in the back.” The CNA said that “when the shower chair with the black seat is wet, it is very slippery and [the resident] started sliding.” The CNA stated that “because she was standing in front of [the resident], she could not put her back into the shower chair so she had to lower her to the ground.”

The state investigator reviewed the resident’s December 5, 2016 MDS (Minimum Data Set) that showed that the severely cognitively impaired resident has inattention and disorganized thinking and impaired range of motion “bilateral to her upper and lower extremities and is totally dependent on to staff members for bed mobility, transfers, and bathing.”

Regency Care of Morris
1095 Twilight Drive
Morris, IL 60450

Because of the substandard level of care provided by the nursing staff that led to a resident hospitalization due to septic shock, the facility was fined $25,000.00.

In a summary statement of deficiency dated May 30, 2017, the State surveyor concluded a complaint investigation and noted that the facility failed to “identify declining wounds, notify the doctor and treat the wound’s deterioration for residents with pressure sores.” As a result of the serious failure by the nursing staff, the resident “was hospitalized and diagnosed with severe septic shock due to an infected left heel wound.”

The investigator reviewed the resident’s MAR (Medication Administration Records) dated between April 1, 2017, and May 18, 2017. “The records document that the last time [the resident’s] left heel wound was treated was May 16, 2017. There is no assessment of the wound on May 17, 2017, or May 18, 2017.”

It was on May 18, 2017, that the resident’s Nursing Progress Notes revealed that the resident’s “roommate alerted the staff to the resident’s loud breathing [who was] observed in respiratory distress, vitals… [with a] temperature of 104.2 axillary.”

Hospital records dated May 18, 2017, from the emergency room stated that the resident “was admitted with severe substance, septic shock, and urinary tract infection. The emergency room report contained pictures of [the resident’s] wounds. The left heel wound was … infected. The wound covered the entire left heel.”

Rosewood Care Center Galesburg
1250 W. Carl Sandburg Drive
Galesburg, IL 61401

The facility was fined $25,000.00 for providing substandard care to a resident who needlessly suffered a broken leg.

In a summary statement of deficiencies dated March 2, 2017, the state investigator noted during a complaint investigation that the facility failed to “implement interventions regarding immediate treatment for a grossly deformed left femur fracture for [a resident].” This failure resulted in the resident “being improperly turned into a position by facility staff without any intervention for pain management or stabilization of unsecured left femur fracture.”

As a result, the resident “remained in the facility without emergent care for seven hours before being hospitalized.” The resident was finally “hospitalized with the spiral fracture to the left femur resulting in blood loss requiring a transfusion.”

The facility’s February 14, 2017 Incident Document that was signed by Licensed Practical Nurse revealed that staff members were “called to the room [at 4:00 AM] by CNAs to check the left thigh [of the resident] and noted lower femur pushing up against the skin causing whitish discoloration with bluish discoloration around the perimeter …. complains of discomfort with range of motion.”

An interview with the Assistant Director of Nurses revealed that they had been asked between 5:00 AM and 5:30 AM to “take a look at [the resident’s] left leg.” The Assistant stated that “I saw an obvious deformity [where the resident’s] femur bone was pushing against the skin slightly to the left of the kneecap. Seem to be internally rotated to the right. I did not check for a pedal pulse. I went out and instructed [the Certified Nursing Assistants to clean the resident …then went to my office to do my duties. The resident’s leg was never splinted. I didn’t direct anyone to splint her.”

It took over seven hours before the resident with obvious signs of a broken femur bone received emergent care at the local hospital for her injuries. The State surveyor fined the facility $25,000 for their substandard care.

Rosewood Care Center of Peoria
1500 W. Northmoor Road
Peoria, IL 61614

Due to providing sub standard care, a bedsore was allowed to degrade into a stage IV pressure ulcer leading to sepsis and hospitalization of the resident, the facility was fined $25,000.00.

in a summary statement of deficiency dated April 13, 2017, the state investigator noted that the facility failed to “identify a pressure ulcer, prevent a pressure ulcer from worsening, obtain a physician ordered treatment for a pressure ulcer, and maintain hand hygiene during pressure ulcer care.” The failure resulted in the resident “being admitted to the hospital with stage IV pressure ulcer and sepsis.” Another resident suffered an “open area worsening to an unstable pressure ulcer.”

The first resident’s ulcers known to be facility-acquired because their Admission Assessment performed and documented the previous month on March 3, 2017, noted that the resident “does not have any open area/ulcers.” However, by March 31, 2017, the Assessment Documentation states that the resident “has an area to [their] left gluteal fold (left ischium) measuring 3.0 cm x 3.0 cm on March 31, 2017.” By April 10, 2017, the wound doctor states that that wound is now “an unstable pressure ulcer covered with necrotic [dead] tissue. The ulcer was caused by prolonged sitting in [the resident’s] wheelchair.”

An interview with a Certified Nursing Assistant providing the resident care stated that “she did not change her gloves during [the resident’s] wound care, and that she should have changed her gloves after cleansing [the resident’s] wound.”

Sharon Health Care Elms
3611 North Rochelle
Peoria, IL 61604

This facility received a fine of $25,000.00 for multiple Type A violations.

In a summary statement of deficiencies dated March 8, 2017, a state investigator noted during an investigation of licensure violations that the facility failed to “implement new fall interventions after a fall, initiate neurological checks and timely reports and investigate a fall for two [residents at the facility].” These failures resulted in one resident “sustaining a subsequent fall on October 21, 2016, that resulted in [the resident] sustaining a Parasymphysis and Rami fracture of the pelvis on October 20, 2016.” The associated Electronic Medical Record documents that the resident expired on October 21, 2016.

The facility’s October 7, 2017, Accident/Incident Report documents of the resident “sustained an unobserved fall on October 7, 2016, at 3:30 AM when the resident ‘was on the bedroom floor fitting in between the bed and wheelchair.” The report also states that on October 21, 2016, at 3:30 AM, the resident “sustained another unobserved fall”. The resident’s medical record contained an x-ray report that identified “right hip, unilateral with pelvis… impression no acute fracture or dislocated dated October 6, 2016. No additional x-ray reports were found in [the resident’s] medical record between October 6, 2016, and October 19, 2016.”

The resident’s November 8, 2016, Certificate of Death Worksheet prepared by the local coroner documents “significant contributing conditions contribute to death… pelvic fracture.”

Washington Christian Village
1201 Newcastle Road
Washington, IL 61571

Due to multiple violations in two incidences involving severe injury the nursing home’s residents, this facility was fined for a total of $50,000.00 in February 2017.

in a summary statement of deficiencies dated February 8, 2017, the state investigator noted after a complaint investigation the facility failed to “ensure a hypotensive resident was not administered antihypertensive medications and blood pressures were monitored for that hypotensive resident.” These failures resulted in the resident “developing severe hypotension, requiring emergent hospitalization, sustaining Cardiac Demand Ischemia following an [unauthorized] antihypertensive medication administration.”

The resident’s 3:45 PM, December 18, 2016, Change in Condition Evaluation documents that the resident “had a change in condition related to abnormal vital signs, food and/or fluid intake was decreased, nausea and vomiting.” The documentation also reveals elevated heart rate (117 beats per minute), respirations at 50 breaths per minute and 93/48 blood pressure. The resident’s doctor was notified and care was ordered and provided in addition to taking vitals routinely. However, the resident’s December 19, 2016, Blood Pressure Log documents that the resident “did not have another blood pressure [monitoring] taken into 2:56 PM [5 hours later,] which was 68/40 mmHg.”

Further documentation notes that on December 19, 2016, the resident “was admitted to the emergency room where laboratory tests were performed. A hospital noted that the resident’s Troponin levels were elevated and were likely caused by a demand ischemia due to [the resident being administered] the wrong medications.

Wentworth Rehabilitation & Healthcare Center
201 West 69th Street
Chicago, IL 60621

Due to multiple violations involving serious incidents of a resident on oxygen smoking inside the facility that ultimately led to a fire that claimed the resident’s life, this facility was fined for a total of $50,000.00 in February 2017.

In a summary statement of deficiencies dated February 9, 2017, the state investigator noted after completing a complaint investigation that the facility had failed to “provide immediate emergency care for resident with a change of condition, failed to develop the care plan for unsafe smoking for a resident, failed to report a resident’s elevated blood glucose level and the resident’s refusal of scheduled insulin to the physician and failed to implement a Care Plan of interventions for resident with diabetes.”

The state investigator noted that these failures resulted in “delayed assessment and care of [a resident] following a facility fire which led to [the resident’s] death.” The initial Incident/Accident Allegation Notification of the facility dated January 1, 2017, indicated that the resident “was observed in the hall with some smoke noted in his room.” The facility’s report dated January 6, 2017, indicates that the resident “was taken to a local hospital and subsequently expired.” The report also indicates that “the police detective and investigator gave a report of the fire was accidental with an unknown origin.”

The resident’s January 1, 2017, Death Certificate indicates the cause of death “was thermal injury and careless use of smoking materials while on home oxygen therapy.” Videotape footage of the event “shows the fire doors… closing at 9:52 AM. The videotape shows a Licensed Practical Nursing at the nurses’ station when the fire doors are closed.” One minute later, the LPN “was observed to take a sip of her drink, stand, walk over to the medication card and place the medication carts behind the nurses’ station [… and] was then observed sitting back down of the nurses’ station to continue her drink.” At no time was the LPN “observed leaving the nursing station to assist during the fire alarm.”

The facility’s Administrator stated that the resident “was not care planned for unsafe smoking with oxygen because it was a behavior at the past facility.” However, the resident’s Behavior Note indicated “please monitor [the resident], he has tried on numerous occasions to smoke in the dayroom, he tries to go to other resident’s room.”

Willow Rose Rehabilitation & Healthcare Center
410 Fletcher
Jerseyville, IL 62052

Due to the substandard care of the nursing staff and their failure to provide CPR in accordance with the resident’s Advance Directive that led to the resident’s death, the facility was fined $25,000.00.

In a summary statement of deficiencies dated April 11, 2017, the state surveyors noted after completing a complaint investigation over licensure violations that this facility had failed to “ensure that all staff has knowledge of the conditions that require the initiation of cardiopulmonary recitation (CPR) for [any resident at the facility].” The failure resulted in “the facility staff failing to follow [the resident’s] Advance Directives by initiating CPR for [a resident] who subsequently expired.”

During a review of records and interviewing staff members, the surveyor determined that the facility “failed to incorporate communicate the resident’s choice for Advance Directives into the resident’s treatment, cares, and services. This failure has the potential to affect 19 of the 23 residents” who have Advance Directives at the facility.

The resident’s MAR (Medication Administration Record) dated March 19, 2017, documents that the resident received “hydrocodone/acetaminophen 5/325 tablet at 8:30 PM.” Ten minutes later, the Nurses’ Notes stated that the “CNA (Certified Nursing Assistant) went down to answer [the resident’s] call light again.” The CNA ran to the nurses’ station stating that the resident had expired. Cap the License Practical Nurse on duty noted that the resident’s “eyes were open, no pulse, no respirations.… The resident was pronounced dead at 8:43 PM.”

The licensed practical nurse stated that “no CPR was performed because [the resident] was already gone, eyes were fixed, and it was very obvious [the resident] was gone.” That LPN also stated that they did not “know the policy on Full Code after someone is obviously dead and doing CPR. I did not do CPR or call 911 either. [The resident] was full code.” The resident’s physician stated that “he expects nurses and Certified Nursing Assistants to perform CPR based on the Advance Directive of the residents and the expectation is for the staff to be trained with current certification to perform CPR.” The physician also stated that “he was aware that [the resident] was a full code.”


Annual Certification Surveys and Unannounced Investigations

The state of Illinois and the federal government through CMS (Centers for Medicare and Medicaid Services) routinely update their websites on the latest information involving the results of annual certification surveys and unannounced investigations involving filed complaints. This data serves as a viable resource for families that are in need of choosing a nursing facility for a loved one.

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