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Illinois Nursing Home Violations (3rd Quarter 2017)

July – September 2017 Quarterly Illinois Nursing Home Report

The Illinois Department of Public Health (IDPH) conducts routine surveys and investigations on nursing homes to determine if any nursing home, rehabilitation center, or assisted living facility has violated regulations in the Nursing Home Care Act. Any serious violation of State and Federal regulations could result in severe penalties and fines.

Please find the report for the Third Quarter here.

Rosenfeld Injury Lawyers LLC remains committed to providing information to the public so that they can make informed decisions about the care of their loved ones in nursing homes. If you believe that your loved one was mistreated or abused in an Illinois nursing home, we invite you to contact our office for a free consultation with one of our experienced attorneys.

3rd Quarter nursing home fines

The state public health department informs the public by releasing quarterly nursing home reports outlining the results of surveys, investigations, and inspections. The Illinois nursing homes listed below were cited for Type A (severe) and AA (extreme) violation occurrences that resulted in fines ranging from $12,500 to $50,000.

Minimum, Average and Maximum Fines

Bethany Rehab & Health Care Center
3298 Resources Pkwy.
DeKalb IL 60115

http://dph.illinois.gov/sites/default/files/publications/NH-17-S0299-06-07-17-Bethany-Rehab-%26-HCC-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 7, 2017, the State surveyor noted that the facility violated four regulations including its failure “to seek emergency medical treatment for a resident with a rapid change in condition. This failure resulted in [the resident] being found unresponsive and requiring CPR (cardiopulmonary resuscitation).”

The nursing staff found the patient unresponsive and without a pulse on December 27, 2016, and placed a call to the resident’s doctor at 12:10 PM. The team performed cardiopulmonary resuscitation (CPR) at 1:00 PM and continued until “paramedics arrived at 1:08 PM.”

The team waited for a call back from the doctor to send the patient to the hospital. The nurse on duty stated that “I was told by the [Director of Nursing and Assistant Director of Nursing] not to send her out because the doctor had seen her prior and to wait for them to call back.” However, the nurse had the patient sent to the hospital after finding the resident unresponsive.

The nurse stated “I knew she was a full code because I checked earlier in the day. I felt like I couldn’t properly do my job. My judgment was to send her out to the hospital. I thought I could get into trouble or lose my job if I sent her out.”

The significant condition change and notification policy of Bethany Rehab & Health Care Center showed that “a significant change in the resident’s physical, mental or psychosocial states: Sudden onset of shortness of breath; a significant change in/or unstable vital signs.

When any of the above situations exists, the licensed [professional shall] contact the resident’s representative and their medical practitioner… The medical practitioner will be contacted immediately for any emergencies regardless of the time of day… If the medical practitioner cannot be reached, the Director of Nursing or Charge Nurse can make arrangements for transportation to the emergency department.”

The State surveyor fined Bethany Rehab and Health Care Center $25,000 for their violation of in-house policies and state and federal regulations.

Champaign County Nursing Home
500 S. Art Bartell Dr.
Urbana, IL 61802

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0296-06-06-17-Champaign-County-Nursing-Home-102317.pdf

Fine:
The State surveyor fined the facility $50,000 for Type AA violations.

Violations:
In a summary statement of deficiencies dated June 6, 2017, the state investigator noted the facility’s failure of six federal and state regulations including their failure to “assess, supervise and provide interventions to prevent self-harm of a resident with known suicidal ideation.” The failure of the facility resulted in the resident’s “self-strangulation and death.” The death involved a resident diagnosed with Major Depression and Anxiety who was admitted to the facility on February 3, 2017.

The February 2017 Physician’s Order Sheet (POS) states that the resident was taking 30 mg of Cymbalta (anti-depressant) every morning. However, the state investigator noted that the Mood and Behavior section of the resident’s Minimum Data Set (MDS) does not document that the resident has “any delusions, hallucinations, behaviors or depression.

There was no behavior tracking documentation made by the facility for [the resident].” Also, the resident’s “Care Plan did not have documentation of goals or interventions addressing self-harm or negative statements about living or dying.”

The state investigator reviewed the resident’s medical record that stated that the resident had “delusions [of] being tied up and held a prisoner in their room.” The Social Service Assistant documented that the resident “has a psychiatric history, exhibits depression, anxiety, and fear.” By February 13, 2017, the resident’s Progress Notes documented that the resident appeared “upset and stated [the resident] was being trapped in the basement and being held captive.”

At approximately 3:00 AM on February 16, 2017, a Certified Nursing Assistant (CNA) stated to a Licensed Practical Nurse that the resident “was yelling and banging on the wall and that [the resident] wanted to die.” The state investigator noted that there was “no documentation of a physician notification.”

By 8:40 AM on February 16, 2017, a Registered Nurse went into the resident’s room and found the resident “undressed down to [their] incontinence brief. A Certified Nursing Assistant (CNA) assisting the resident in dressing to transport [the resident] to the dining room stated that at 8:45 AM they found the resident “holding a stretch band around [their own] neck.”

The resident had no pulse and was unresponsive. The medical team began cardiopulmonary resuscitation and called 911 for transport by ambulance to the hospital at 9:10 AM. A coroner’s report dated the same day indicates that the “Deputy Coroner was notified at approximately 9:59 AM of [the resident’s] death in the emergency room.” The facility was fined $50,000 for not following protocols in assessing the patient’s needs and providing supervision and care.

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a separate summary statement of deficiencies dated June 26, 2017, the state investigator’s noted the Champaign County Nursing Home’s failure to “ensure the door alarmed to the courtyard of the facility’s Alzheimer’s Unit was engaged [and that the] door was not propped open.”

The investigator’s noted that “this failure resulted in the door alarmed being disengaged, the door propped open and [the resident] wandering into the courtyard and remaining unsupervised for over three hours in direct sunlight with temperatures exceeding 85°F.”

Because of the lack of supervision during the incident, the resident “was found unresponsive, having vomited, without vital signs and subsequently died.” After the investigation, the State surveyor fined Champaign County nursing home $25,000 for their negligence.

Citadel Care Center – Elgin
180 S. State Street
Elgin, IL 60123

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0319-06-02-17-Citadel-Care-Center-Elgin-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 2, 2017, the state surveyor followed up on a complaint investigation and noted the facility failed to “ensure all hospital discharge medication orders are followed and provided to residents.” The failure by the nursing staff and administration resulted in the resident “not receiving 8 of 16 medications for three weeks (from April 25, 2017, through May 15, 2017 – 21 days). These medications included anticoagulant, antiarrhythmic, and diuretic medications.”

As a result of the negligence of the nursing staff, the resident developed severe congestion and shortness of breath on May 15, 2017, and “was admitted to the hospital’s intensive care unit with diagnoses including sepsis [blood infection], pneumonia and congestive heart failure.” The state investigator noted that “there was no documentation found in [the resident’s] electronic clinical record or presented as to why these medications were discontinued or that the attending physician was notified.”

On June 1, 2017, the nurse providing care made a statement that the resident “was very congested. I do not need to use a stethoscope. I can hear him from the hallway, he was gurgling so loud. So, I ask the Nurse Practitioner to come in and evaluate him.”

That same day, the facility’s Admission Director presented the hospital’s History and Physical (H & P) Emergency Record showing how the resident “is currently in the hospital’s intensive care unit, comatose and has diagnosis to include acute sepsis, pneumonia, and congestive heart failure.” As a result of the negligence by the nursing staff, the facility was fined $25,000 for violating nursing home regulations.

Collinsville Rehab & Health Care Center
614 N. Summitt
Collinsville, IL 62234

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0306-06-20-17-Collinsville-Rehab-%26-Health-CC-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 20, 2017, the state investigator fined the facility for five licensure violations. These violations include a failure to “provide and administer insulin medication and [a failure to] monitor blood glucose levels for [a resident that resulted in the resident] being sent to the hospital and admitted to the Intensive Care Unit for Diabetic Ketoacidosis.”

The resident’s June 9, 2017, Care Plan Master Listing shows that the resident “was admitted with a diagnosis of Diabetes capsulitis and Diabetic Ketoacidosis and needs monitoring for Hypoglycemia/Hyperglycemia” with an approach that involved “close monitoring of blood sugar and give sliding-scale insulin as ordered and daily insulin as ordered.”

However, at 8:30 AM on June 12, 2017, the resident’s Nurse’s Notes revealed that the “Resident was found in the room during breakfast having increased respirations and difficulty being aroused. Due to patient being diabetic, she was sent to [the city hospital] via paramedics, staff waited for paramedics.”

According to the Emergency Medical Services report it was revealed that “the patient did not receive any insulin over the weekend, patient’s blood sugar was greater than 600 upon EMS arrival.” The hospital treated the resident with “insulin infusion.”

The facility’s Administrator was interviewed on the morning of June 20, 2017. It was revealed that the facility’s Interim Director of Nursing told her “on Monday morning [that] on June 12, 2017 [the resident] did not get any insulin.” The Administrator said that the resident’s “insulin did not get in the facility and orders to transfer to the hospital due to high blood sugar levels.”

The facility’s Medical Director stated that “it is obvious that [the resident did not receive] insulin over the weekend [which was] a contributing factor to [the resident’s] diabetic ketoacidosis….” The state investigators issued a fined against the facility $25,000 for their violations and negligence in providing substandard care to the resident.

Daystar Nursing & Rehab Center
2001 Cedar St.
Cairo, IL 62914

http://dph.illinois.gov/sites/default/files/publications/NH-17-S0354-06-13-17-Daystar-Nursing-%26-Rehab-Center-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 13, 2017, the state investigator noted that the facility had violated six state and federal nursing home regulations. This included the facility’s failure to “ensure Uniform Advance Directive forms were correctly completed in accordance with each code status as designated by the resident or legal representative.

Staff did not perform cardiopulmonary resuscitation (CPR) despite written physician’s orders and in accordance with [the resident’s] legal representative’s requirements.” As a result, the resident “subsequently expired.”

The state investigator reviewed the resident’s March 30, 2017, MDS (minimum data set) and DNR (uniform Do-Not-Resuscitate) Advanced Directives/Practitioner Orders for Life-Sustaining Treatment form.” The investigator noted that under Section A, an ‘X’ had been placed in the box beside the “Do Not Attempt Resuscitation/DNR.” It was also noted that “the box beside the words ‘Attempt Resuscitation/CPR (Cardiopulmonary Resuscitation) is missing.”

The document also was missing a box denoting that the individual signed the form and was missing the words “Signature of Patient or Legal Representative” and “Signature (required).”

DeKalb County Rehab and Nursing Home
2600 N. Annie Gliddon Rd.
DeKalb IL 60115

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0341-06-28-17-DeKalb-County-Rehab-%26-Nursing-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 28, 2017, state investigator noted the facility violated four state and federal regulations including the facility’s failure to “identify agitated behaviors for a Dementia resident as an indicator of pain. The facility failed to assess swelling of a resident’s leg on June 11, 2017. These failures contributed to [the resident] having a delay in treatment [and] was found to have a femur fracture and a deep vein thrombosis on June 12, 2015.”

State investigators noted that the resident had “bumped her leg on her wheelchair a couple of weeks ago [… and] bumped her legs on the chair.” According to the resident’s roommate, the resident was “sent to the hospital” the day after this incident.”

On June 20, 2017, a Certified Nursing Assistant (CNA) providing the resident care on June 11, 2017, said that the “first shift staff reported to her that [the resident] had been screaming all day.” The CNA also stated that the resident “was screaming at the top of her lungs… Like in a panic.” The resident was “very stiff and could hardly move… [and was] anxious, panicked.”

On this day and the subsequent day of June 12, 2017, the Registered Nurse (RN) providing the resident care stated that the resident was “complaining of pain in her left arm, right arm, and her left leg.” The RN said that she noticed that the resident’s “left knee was swollen.”

Finally, after the second day of complaining, the resident was transported to the hospital. The June 12, 2017, Hospital History and Physical revealed that “during the initial evaluation, the emergency department patient has undergone extensive evaluation and she has been diagnosed to have an oblique fracture through the left distal femur extended to the joint space. venous ultrasound Doppler of the lower extremity was positive for acute deep vein thrombosis involving left common femoral vein to the left posterior tibial and peroneal veins.”

Because of the substandard care provided to the resident in a time of crisis, the facility was fined $25,000 for their negligence.

Forrest City Rehab & Nursing Center
321 Arnold Ave.
Rockford, IL 61108

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0395-07-18-17-Forest-City-Rehab-and-Nursing-Center-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated July 18, 2017, the state investigator noted the facility violated eight state and federal nursing home regulations. These violations included the facility’s failure to “administer medications in a manner to avoid a significant medication error.” This error resulted in [a resident receiving opioid medications that should have been administered to four other residents].”

The surveyor also noted that “the facility failed to provide the necessary care and services by not assessing, documenting vital signs, and monitoring for a declining condition for a resident that received multiple opioid medications in error. These failures contributed to the resident becoming unresponsive and requiring emergent opioid reversal medication.”

It was also documented that the “facility failed to inform the resident’s power of attorney (POA) for health care regarding an incident that required physician intervention and a significant change in the resident’s condition.” It was also documented that the facility “failed to follow physician’s orders by not monitoring [the resident’s] vital signs every hour after the medication error occurred.” Due to the substandard level of care provided to the resident, the facility was fined $25,000 for multiple violations.

Friendship Village – Schaumburg
350 W. Schaumburg Rd.
Schaumburg, IL 60194

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0316-06-01-17-Friendship-Village-Schaumburg-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 1, 2017, the State surveyor noted the facility violated four state and federal regulations. These licensure violations included the facility’s failure to “implement individualized fall risk interventions for residents identified as a high fall risk, and failed to identify and implement new interventions to prevent further falls.”

It was also stated that the failure resulted in a resident “sustaining a right hip fracture [… and a second resident fell resulting in an] intracranial hemorrhage.” This failure also affected a third resident causing a psychosocial impact “who now fears leaving his room to eat in the dining room.”

The state investigator noted that the nursing staff failed to follow their October 28, 2015, policy titled “Falls – Clinical Protocol” that states:

  1. For an individual [who has fallen], staff should attempt to define possible causes within 24 hours of the fall.
    a. After the first fall, the staff (and physicians, if possible) should watch the individual rise in a chair without using his or her arms, walk several paces, returned to sitting. If the individual has no difficulty or unsteadiness, further evaluation may not be needed. If the individual has difficulty or is unsteady when performing this test, additional valuation should occur.”
    Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions and try to prevent subsequent falls into address risks of serious consequences of falling.
  2. If the underlying cause cannot be readily identified or corrected, staff will try various relevant interventions, based on an assessment of the nature of category of falling until falling reduces or stops or until the reason is identified for its continuations.
  3. The staff and physician will monitor and document the individual’s response interventions intended to reduce falling or the consequences of falling.
  4. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident’s falling …and will reevaluate the continued relevance of current interventions.

Because the staff provided substandard care that led to serious falls with consequences, the state and federal investigators issued a fine of $25,000 against Friendship Village – Schaumburg for multiple violations.

Glenshire Nursing & Rehab Centre
22660 S. Cicero Ave.
Richton Park, IL 60471

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0408-07-31-17-Glenshire-Nursing-%26-Rehab-Ctre-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated July 31, 2017, the State surveyors investigated a complaint involving six state and federal nursing home violations at Glenshire Nursing and Rehab Centre. These violations included the facility’s failure to “provide wound treatment as prescribed, [and a failure] to prevent wound infection and [a failure to reposition three residents] at least every two hours” for pressure ulcers. “As a result, [one resident] was admitted to the hospital for sepsis [blood infection] and necrotic wound resulting in surgical wound debridement.”

The resident’s April 30, 2017, Wound Care Note indicates that there was a “right hip wound assessed for surgical consult by a physician.” The document also states that the resident “needs to be sent out to the hospital related to an infected necrotic hip wound.”

The resident’s April 30, 2017, Hospital Records indicates that the resident “was admitted with a chief complaint of necrotic wound and sepsis.” The hospital doctors determined that the resident “had a decubitus ulcer to the right hip that a need surgical debridement.”

The hospital records dated May 2, 2017, indicates that the resident “had an excisional debridement of the right hip wound [that measured 16cm × 13 cm] involving skin, subcutaneous tissue, fat, muscle and fascia.” The records also described the “area of necrotic tissue identified to the right hip with frank pus draining out of the area of necrotic tissue.”

The procedure revealed that the decubitus (bedsore) ulcer had eaten away bone which is “indicative of osteomyelitis [bone infection].” The resident’s blood culture drawn that same day indicated “Graham positive bacilli.”

The state investigators issued a fine of $25,000 against Glenshire Nursing and Rehab Center for their failure to follow their in-house July 2011 Pressure Ulcer Prevention policy that indicates that “residents who are unable to turn reposition independently will be assisted to turn [and] reposition every two hours or as appropriate.” The facility’s July 2007 Wound Cleansing and Dressing policy states that “underdressing changes to apply new dressing after cleansing the wound per physician orders.”

Heartland of Peoria
5600 Glen Elm Dr.
Peoria, IL 61614

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0314-06-26-17-Heartland-of-Peoria-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 26, 2017, the state investigators issue two fines against Heartland of Peoria for violating three federal and state nursing home regulations. These violations included the facility’s failure to “provide and document sufficient preparation and resident orientation in order to ensure safe and orderly discharge from the facility.”

Also, the facility “failed to return personal belongings, cell phone and home keys upon discharge… This failure resulted in [the resident] spending the night on his porch during 90°F temperatures. Subsequently, [the resident] was hospitalized for edema after being sunburned and sitting in feces overnight.”

The state surveyors noted that the facility failed to follow their December 2009 Discharge: Home or Non-Institutional Setting policy that reads in part:

“To provide a safe departure from Center to Home for non-institutional setting… Procedure: Day of Discharge to Home or Non-Institutional Setting” to “Complete discharge summary paperwork and place into medical record.”

The facility’s Assistant Director of Nursing stated that “My Transition Home is the discharge instruction packet for residents, with instructions regarding equipment needed, medications, appointments.” The Director stated that the resident’s “discharge instruction packet was not completed prior to discharging [the resident to their] home on June 14, 2017.

The Director also verified that the resident policy is to issue “discharge instructions and education by Nursing, Social Services and Therapy [which were] were blank and should have been completed for [the resident] prior to [the resident’s] discharge home.” The facility’s 3:15 PM June 14, 2017, Electronic Clinical Record involving a Progress Note revealed that “patient discharged to home with belongings. Transported per facility van.”

The chauffeur trainee working for the facility stated that the resident “had discharge papers from the facility in his possession upon discharge…” Upon arrival at the resident’s house, the chauffeur stated that he and the resident “checked the front and back doors and discovered both doors were locked.”

The chauffeur verified that the resident mentioned that he “did not have his house keys.” At that time, the chauffeur left the resident’s “house to return to the facility and last saw [the resident] sitting in his backyard at approximately 3:45 PM on June 14, 2017.”

The facility’s Administrator stated at 1:30 PM on June 21, 2017, that the resident’s “cell phone and house keys were located in the narcotic box in the facility’s medication card and he delivered them to [the resident] at the hospital earlier that morning.” Because of the facility’s negligence in ensuring the safety of the resident discharged from Heartland of Peoria, they were fined $25,000 for their violations.

Hillcrest Retirement Village
1740 N. Circuit Dr.
Round Lake Beach, Illinois 60073

http://www.dph.illinois.gov/sites/default/files/publications/July-Sept-2017-QRPT-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 14, 2017, state investigators conducted an incident report investigation involving a May 29, 2017, incident concerning four licensure violations. This investigation involved the facility’s failure to “assess and effectively maintain pain prior to dressing changes.

This failure resulted in [a resident] experiencing unrelieved pain during two burn wound dressing changes.” The incident involved a resident whose June 6, 2017, MDS (Minimum Data Set) revealed “moderate cognitive impairment and requires extensive staff assistance with bed mobility, locomotion, dressing, and hygiene.”

The resident’s May 29, 2017, Care Plan revealed a focus area involving a “burn on the left and right medial thigh. The intervention section state: Cleanse left and right medial thighs using wound cleanser, apply Santyl and covered with dried gauze dressing once daily until resolved. Monitor dressing once every shift and change if saturation is more than 50%…”.

Observation of the wound care nurse on the morning of June 13, 2017, noted that the resident’s “hands were clenched, and face was grimaced” while the Wound Care Nurse performed dressing changes. “Clear liquid was oozing out of each wound.” During the procedure, the resident stated that “I don’t know what’s going on right now. My leg hurts. Ouch!!”

The Wound Nurse was “observed cleansing both thigh wounds while [the resident] continued to say, ‘OOOOO’ and ‘Ohhh boy!’ throughout the dressing change.” The resident repeatedly said, “Don’t hurt me anymore,’ and ‘both my leg hurts.”

The Wound Nurse stated “he did not know when [the resident] last received pain medication and he did not administer any type of pain medication prior to beginning the dressing changes.

In a related summary statement of deficiencies dated June 14, 2017, the state investigator noted the facility’s failure “to ensure resident safety and supervision for cognitively impaired residents when drinking hot tea.” The failure of the nursing staff resulted in the resident “sustaining second and third-degree burns on her thighs and [another resident] sustaining a first-degree burn to her thigh.”

Due to the lack of providing quality care in a safe environment, Hillcrest Retirement Village received a $25,000 fine for serious violations.

Hope Creek Care Center
4343 Kennedy Dr.
East Moline, IL 61244

http://www.dph.illinois.gov/sites/default/files/publications/July-Sept-2017-QRPT-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 13, 2017, the state investigators issued a fine against Hope Creek Care Center involving five licensure violations. These violations included the facility’s failure to “assess side rails for entrapment risk prior to use for [a resident] reviewed for side rails.”

The failure of the nursing staff resulted in the resident’s “head becoming entrapped between the side rail and mattress. The facility continues to use the same unsafe side rail despite [the resident’s] previous entrapment and subsequent fall from the bed.”

The investigators noted that the facility failed to follow their in-house December 20, 2016 policy titled: Restraint Free that reads in part:

“Prior to the use of any side rails, a bed mobility assessment must be conducted by a therapist or licensed nurse. The resident must be able to demonstrate that they are capable of using them for bed mobility. If side rails are utilized, they must be fitted appropriately to the bed.”

The resident’s March 16, 2017, Nurses Notes revealed that the resident was found in their bedroom saying, “Help Me!” At the time, the resident was “found with knees on the floor wrapped in a blanket with [their] head wedged between the side rail and the mattress.” The resident was heard saying they “needed to use the restroom.”

The same resident’s June 4, 2017, Care Plan documents that the resident “is at risk for falls related to confusion, medication use.” The resident “is independent of bed mobility and ambulation with supervision.” Because of the lack of supervision and substandard care in ensuring the resident’s safety, Hope Creek Care Center received a fine of $25,000 from the state investigators.

Integrity Healthcare of Godfrey
1623-39 W. Delmar Ave.
Godfrey, IL 62035

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0353-06-22-17-Integrity-HC-of-Godfrey-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 22, 2017, the state investigators found five serious licensure violations and issued a fine against Integrity Healthcare of Godfrey for $25,000. These violations included the facility’s failure to “provide pain management for [two residents].” The failure of the nursing staff resulted in the resident “experiencing severe pain exhibited by him crying and having an increased level of anxiety following admission to the facility from the hospital.”

The 56-year-old male resident’s April 26, 2017, Admission Record revealed that he had arrived from the hospital after surgery for rapidly progressive Fournier’s gangrene. The resident’s April 26, 2017, Hospital Discharge Orders included hydromorphone, morphine, and acetaminophen pain medications to alleviate pain and fever along with hydrocodone acetaminophen and tramadol when needed for pain.

However, at 2:13 PM on June 20, 2017, the resident “stated he did not get any pain medication after being [arriving] at the facility until the next day. When [the resident] was asked to describe the pain, [he] described it as ‘horrible’ and added that he was crying [because] he was in so much pain.”

The resident also stated that “he was told by the admitting nurse that none of his medication, including his pain medication, would be in until the next day as it came from the pharmacy in (a Southern Illinois City).” The resident stated that “he laid in bed all night. When asked to describe the pain the night of his admission, [the resident] stated it would have been a “10” all night.”

The second resident involved in the violations is an 84-year-old female admitted to Integrity Healthcare of Godfrey on May 16, 2017 “from the hospital following a surgical repair of a fractured left hip. The resident was admitted to the facility with hospital discharge orders for tramadol taken as needed and Tylenol given every 2 to 4 hours [as needed] for mild pain.

Like the first incident, the resident recalled “the night she arrived at the facility stating that it was ‘terrible’ that night as they did not have to her pain medication available to the next day.” The female resident stated that “she has moderate pain in her left thigh area and rubbed it as she spoke.”

The resident stated that “she did get Tylenol the next day but had to wait for the tramadol.” The state investigator interviewed the resident’s primary physician who stated that “nurses to have utilized the E-Box for [the resident’s] pain medication.”

Lexington Health Care Center – Lombard
2100 S. Finley Rd.
Lombard, IL 60148

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0398-08-17-17-Lexington-Hlth-Cr-Ctr-Lombard-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated August 17, 2017, the state investigators fined Lexington Health Care Center – Lombard for violating five major state and federal nursing home regulations. These violations included the facility’s failure to “ensure that a resident was safely transferred by staff.

The facility also failed to ensure that the wheelchair monitoring devices are in working condition. This failure to safely transfer a resident resulted in a traumatic fall causing a complete displaced spiral fracture involving the distal left femoral shaft.”

The facility’s April 7, 2017, Final Incident Report revealed that the resident “sustained a fall at the bedside during a.m. care. The report further describes ‘after receiving a.m. care at the bedside; the resident reported sitting at the edge of the bed as staff attempted to transfer.

The resident [said] he started sliding to the floor, staff attempted to break the fall, unable to do so and lowered the resident to the floor.” The staff failed to use a gait belt as required to provide more control during the transfer.

The resident’s April 7, 2017, Progress Note documents that the resident “has a left knee swelling and lower leg pain. Stat x-ray was ordered, and the result was displaced left femur fracture, the physician was notified and [the resident] will be sent to the local hospital for orthopedic evaluation.”

Parkway Manor
3116 Williamson Co. Parkway
Marion, IL 62959

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0357-06-21-17-Parkway-Manor-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 21, 2017, state surveyors conducted an investigation concerning a complaint involving three licensure violations. The violations included the facility’s failure to “prevent a resident from falling out of bed, while soiled bed linens were being changed.”

The failure by the nursing staff resulted in the resident “falling from the bed and sustaining significant complex lacerations to the nose and left brow that required extensive surgery.”

The resident’s May 4, 2017, Admission Records revealed that the resident was diagnosed with “fractured talus (ankle) bone, vascular dementia, and seizures. The resident’s May 10, 2017, Care Plan revealed the resident “requires two staff to assist with transfers… can bear weight as tolerated from the left leg …wears a boot on the left leg.” The resident’s May 20, 2017, MDS (Minimum Data Set) revealed that the resident “requires 3/3+ assistance to transfer to bed…”

The resident’s June 3, 2017, Nurses Notes revealed that a Certified Nursing Assistant (CNA) reported that the resident “rolled out of bed [in a] prone position to the floor next to the bed.” It was documented that there was “moderate amount of bright red bleeding controlled with pressure.

Laceration to the left side of the face and nose. No difficulty breathing. Moving extremities per self. Answering questions are properly. Resident remains on the floor. Ambulance notified.”

An interview with the CNA revealed that the resident “fell from the bed” while the entire bed was being changed. Even though the CNA asked for assistance, two Certified Nursing Assistants stated that “she could change [the resident] by herself” even though she had “never changed [the resident] by herself.”

The CNA stated that she went into the resident’s room alone “and loosened the soiled sheets” stating “I was trying to roll over. I told her to stop, and she continued to roll out of bed onto the floor… away from her.” The injured resident was sent to the hospital and discharged to the family who relocated her into “another long-term care facility.”

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

http://dph.illinois.gov/sites/default/files/publications/NH-17-S0331-06-16-17-Rosewood-Care-Center-Galesburg-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 16, 2017, state surveyors issued a fine of $25,000.00 to Rosewood Care Center of Galesburg for five licensure violations. These violations included the facility’s failure to “notify the family and the physician for a change in condition” involving two residents.

The failure by the nursing staff resulted in one resident’s “pressure ulcer deteriorating and requiring surgical incisional debridement.” Another resident developed “episodes of brown, coffee ground emesis, with no documented assessment, monitoring, or physician notification for over 20 hours” which resulted in the resident’s need for “hospitalization with urosepsis.”

At approximately noon on June 16, 2017, the Wound Physician providing care to the resident with pressure ulcers stated that “I was not notified of the change in [the resident’s] wound until last evening (June 15, 2017). I saw [the resident’s] coccyx wound today (June 16, 2017) and it had deteriorated. I expected to be healed by now. The last time I saw the wound, it was very small.”

The physician also stated that “wounds are to be measured weekly, [and] somebody is supposed to do it. I expect to be notified right away if there is a change in the wound. I was on vacation last week, but they could have sent [the resident] to the wound clinic to have the wound assessed. I had to surgically debride the necrotic [dead] tissue today, and the wound is larger.”

In the other incident, a physician assistant at the facility stated on June 15, 2017, that “we would expect to be notified of any significant change in a resident’s condition. If it is not during office hours, there is a paging system to reach the person on call.” Two days earlier a Registered Nurse providing care to the other resident who developed episodes of brown, coffee ground emesis stated “I got a verbal report that [the resident] was puking bile, and the stomach flu had been going around, so I was going to monitor the situation.

Then, after the first time observed [the resident’s] vomit I immediately called [the resident’s family representative] and [physician] because the emesis was coffee ground in nature.”

Snyder Village
1200 E. Partridge
Metamora, IL 61548

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0405-07-27-17-Snyder-Village-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated July 27, 2017, the state surveyors investigated a licensure violation complaint involving four state and federal nursing home regulations. The violations included the facility’s failure to “assess for adequate hydration for [a resident] reviewed for hydration…”

This failure by the nursing staff resulted in the resident “requiring hospitalization for intravenous fluid, medications to increase [the resident’s] blood pressure, and antibiotics for the treatment of Sepsis, Severe Dehydration, Acute Kidney Injury, and Altered Mental Status.”

A second violation involved neglect at the facility “to provide prompt medical care following a change in mental status and abnormal vital signs, [and a neglect] to assess once a change in condition was noted, and [a neglect to] monitor for fluid intake for [a resident at the facility].” The negligent actions of the nursing staff resulted in the resident “requiring hospitalization for intravenous fluids.”

A third violation involved the facility’s failure “to properly notify physician of the resident’s change in a level of consciousness…” This failure by the nursing staff “resulted in a delay of treatment for [the resident who required] hospitalization for intravenous fluid, medication to increase [their] blood pressure, and severe dehydration.”

The neglected resident was transferred to the hospital to receive emergent treatment. Hospital records indicate that the resident “was so severely dehydrated that her lips were cracked and dry, and her mucous membranes were extremely dried.” The hospital treating doctor stated that the resident’s “dehydration was so severe that [the resident] was hypotensive (low blood pressure) and required intravenous fluids and a drug called levophed to help increase [their] blood pressure.”

The doctor also stated that the low fluid volume in the resident “resulting kidney damage” and that the resident “did not become so dehydrated in just one or two days.” The dehydration caused the resident to have “a decreased level of consciousness and was unable to answer questions the whole time [they were] in the emergency room.”

The Springs at Crystal Lake
1000 E. Brighton
Crystal Lake, IL 60012

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0405-07-27-17-Snyder-Village-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated May 25,017, the state surveyors conducted a complaint investigation survey involving seven licensure violations. These violations included the facility’s neglect in following “its Resident Examination and Assessment policy and Change in a Resident’s Condition or Status policy when staff failed to assess comprehensively and immediately notify the physician when a diabetic resident’s condition deteriorated on May 11, 2017.” The failure to provide a minimum standard of care contributed to the resident’s “continued deterioration and delay in emergency treatment.”

Documentation reveals that the resident “was noted to be confused at 5:00 PM, increasingly of lethargic at 6:30 PM, and was unresponsive at 7:00 PM, 7:30 PM, and 8:00 PM.” Even with these notable problems, the nursing staff failed to provide immediate intervention and allow the resident’s condition to continue “to deteriorate for approximately 90 minutes before the facility sought Emergency Medical Services (CMS) at 8:23 PM”.

The emergency team found the resident “to be unresponsive, with cold and clamming skin. As a result [the resident] was hospitalized in a diabetic coma, with hypothermia and acute respiratory failure.”

The state investigator noted the facility failed to follow nursing intervention guidelines as outlined in their undated Diabetes Mellitus: Prevention and Emergency Treatment of Hypoglycemia policy that reads in part:

“Low blood glucose (70 mg/dL or below) and symptoms of severe hypoglycemia” guides the nursing staff to “elevate the head of the bed… Administer the physician’s orders for emergency treatment of severe hypoglycemia. If orders are not present than implement the procedure below and instruct another nurse to notify the position of blood glucose values.”

Because of their failure to provide a minimum standard of care to the resident and crises, The Springs at Crystal Lake Center was fined $25,000 by the Illinois Department of Public Health.

Symphony of Joliet
306 N. Larkin Ave.
Joliet, IL 60435

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0317-06-01-17-Symphony-of-Joliet-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 1, 2017, state surveyors conducted a complaint investigation survey involving four licensure violations. The survey included a violation of the facility’s failure to “implement preventative fall measures.” The failure by the nursing staff resulted in the resident “incurring a right femoral neck fracture and [another resident] incurring the left four head laceration requiring sutures.”

In the first incident, a member of the nursing staff providing care to the resident noted: “falling was the first responded to [their] room.” The staff member found the resident on the floor and stated that there were “no alarms sounding in [the resident’s] room.

The facility’s June 24, 2017, Final Incident Report documents that five days earlier on June 19, 2017, at 2:48 PM, the resident “was found on the floor of [their] bedroom. Since then, the resident has complained “of pain in the right hip, elbow, and knee and was transferred to the hospital for evaluation. At the hospital, [the resident] was diagnosed with a right femoral neck fracture requiring surgical repair.”

The facility’s Medical Director confirmed in the early afternoon of June 1, 2017, that “the facility should implement measures to keep a resident safer and [to implement recommended fall interventions].” The surveyors stated that the facility failed to follow their August 2014 Fall Policy that states that the Home “will identify and evaluate those residents at risk for falls, plan for preventative strategies and [keep the] facility as safe an environment as possible.”

Thomas Lombard House
4129A North Route 1 & 17
Momence, IL 60954

http://dph.illinois.gov/sites/default/files/publications/NH-17-S0311-06-20-17-Thomas-Lombard-House-102317.pdf

Fine:
The State surveyor fined the facility $12,500 for Type AA violations.

Violations:
In a summary statement of deficiencies dated June 20, 2017, state investigators conducted a licensure violations survey concerning three nursing home regulations. The violations included the facility’s failure to “provide operating direction and oversight resulting in systemic failures” affecting 15 the residents at the facility. These failures include:

  1. “Prevent neglect for [one resident] when the staff failed to provide the necessary monitoring and supervision required to ensure his physical safety.” The resident “was taken on a community outing and left on the bus for approximately two hours in documented 90+ degree weather and expired.
  2. “Ensure individuals’ welfare are monitored and attended to for [15 residents].”
  3. “Ensure staff [completed] necessary competency-based training to provide needed monitoring and intervention services [for 15 individuals in the facility]. The facility failed to provide documentation of protocols to be taken when residents are taken on community outings.”

The investigator noted that the facility “could not provide documented evidence that ongoing monitoring of individuals’ welfare and safety was being done” and that the facility “was unable to provide evidence of the policy and procedure for outings in the community.” It was also noted that the Thomas Lumbar House “was unable to provide documentation of the individuals participating in the outing on June 11, 2017” and could not “produce documented evidence of a client consensus at the 4:00 PM shift change on June 11, 2017.”

United Methodist Village North Campus
2101 James St.
Lawrenceville, IL 62439

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0285-05-10-17-United-Methodist-Village-North-Campus-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated May 10, 2017, the state surveyors investigated two filed complaints involving three licensure violations. These violations included the facility’s failure to “secure a mechanical lift sling to the mechanical lift hooks and implement fall prevention interventions for [a resident at the facility].”

The failure by the nursing staff resulted in the resident “falling out of a mechanical lift, sustaining bilateral femoral fractures, and undergoing an open reduction internal fixation surgical procedure for those fractures.”

The facility’s May 13,017 3:45 PM Central Office Notification Report stated that the resident “fell in his room while transferring… Sent to [the hospital] for evaluation.” Documentation from the hospital revealed that the x-ray showed “bilateral distal femoral fractures” and that the resident was “being sent onto [an out-of-state hospital] for an orthopedic consult.”

Documentation from the local hospital reports that the 86-year-old male resident from the nursing facility arrived with “pain in both knees, right hip, and also hit his head. Was being transferred [while] at the nursing facility in a Hoyer lift and …fell with resultant injuries.”

The facility’s May 13, 2017, Personal Action Forms revealed that the incident on the previous day involving two Certified Nursing Aides (CNA). These two CNAs “received written disciplinary action for ‘Improper use of a Hoyer [lift] – did not get pad correctly attached – resident fell off the lift pad and had a serious injury.”

The Director of Nursing stated on May 15,017 during an interview that “as a result of our investigation, we determined the mechanical lift sling loop wasn’t hooked on the lift hook properly, which caused the left side of the sling to give way and [the resident] fell. We disciplined both CNAs and took the lift out of use and started using another lift we had in the building at the time we were considering purchasing.”

Warren Barr Lincolnshire
150 Jamestown Ln.
Lincolnshire, IL 60069

http://dph.illinois.gov/sites/default/files/publications/NH-17-C0320-06-01-17-Warren-Barr-Lincolnshire-102317.pdf

Fine:
The State surveyor fined the facility $25,000 for Type A violations.

Violations:
In a summary statement of deficiencies dated June 1, 2017, state surveyors made final observations of licensure violations at the facility. These violations included the facility’s failure to “identify a resident with a history of falls as high-risk for falls and [a failure] to implement safety interventions.

The facility failed to supervise a resident with a history of falls during toileting.” The surveyors also noted that the facility failed “to safely transfer a resident who is at risk for falls with the gait belt. The facility failed to ensure a personal safety alarm was in working order.” The failures by the nursing staff resulted in the resident “sustaining C-1 and C-2 fractures and experiencing a decline in activities of daily living.”

The resident’s Care Plan revealed that the resident “is at high-risk for falls and has interventions to observe for changes in ability to ambulate or locomotive. The document stated that “side rails as ordered, observed resident’s gait for steadiness and balance, muscle coordination, and ability to turn and reposition self, keep call lights within reach when in bathroom or restroom, and use of a wheelchair for an assistive device.

Documentation revealed that the resident first fell on June 16, 2017, and “was found by Certified Nursing Assistant (CNA) on the bathroom floor.” The resident “told the nurse [who was] writing the report ‘I was on the toilet and got to wash my hands [when] my legs gave out.’” Even though the resident had fallen the previous day, the June 17, 2016, Fall Risk Assessment revealed that the resident “is a low-risk for falls and the section for recent falls is marked ‘no.”

The resident’s second fall occurred on November 16, 2016, when a CNA “observed the resident “leaning off of his motorized wheelchair.” The resident “reported he had fallen off his chair while reaching for his heater.” The resident’s Fall Risk Assessment dated the next day after the fall revealed that the resident “is a low-risk for falls in the section for recent falls is marked ‘unknown.’”

The facility reported that the resident had a third fall that occurred on February 19, 2017, when the resident “was found by the activity aid on his bathroom floor yelling for help.” At this time, the resident “was transferred back to bed and complained of neck pain.

The doctor was informed of the fall, and an order was obtained to send [the resident] to the hospital.” The hospital reported that the resident showed “acute fractures of C-1 and C-2 (neck).” The resident “was admitted for further evaluation and management.”

Additional Information

The Centers for Medicare and Medicaid Services (CMS) routinely update their nursing facility rating system that ranks overall performance and specific data on how facilities guard the health, safety, and well-being of the residents. Many family members use the rating system as an effective tool to determine where to place a loved and who requires personalized medical and hygiene care.

Many of the nursing homes that received severe penalties and fines continue to provide services to Illinois residents.

Are You Concerned About a Family Member in an Illinois Nursing Facility?

Perhaps you encountered a recent incident which is cause for concern. Perhaps your witnessed a rapid decline in the functionality of your loved one. Most episodes of poor care remain unprosecuted. If your loved one has experienced any of the following, it may be reason for concern.

We invite you to contact our office anytime for a free and confidential case review.