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Articles Posted in Quarterly Violator List

We continue our look at Chicago nursing homes that were recently cited for violations by the Illinois Department of Public Health. Earlier this year Alden Wentworth Rehab Center, a facility located on West 69th Street, recently received several Type “A” Violations from the Illinois Department of Public Health and was fined $20,000. The violations were given as a result of various acts of negligence, including failure to investigate allegations of residents abusing one another and the facility’s failure to follow even basic nutrition guidelines in feeding residents.

When inspectors visited the facility, they noticed that the meal being served for lunch appeared to be quite small. A hamburger was served that weighed only 2.2 ounces. It was also documented that many residents were not fed lunch until late. Other basic nutritional procedures were not followed by the staff members of the facility.

In addition, the Chicago nursing home breached its own policy protocol after one female resident accused a male resident of sexually assaulting her-no investigation or action of any kind was taken by the nursing home. The victim reported being approached by the aggressor while she was in bed. He tried to kiss her but she rebuffed him. The man then became forceful, eventually touching her inappropriately.

Even after the incident, the aggressive resident had free reign of all the floors and locations in the facility. At the time of the nursing home inspection, little to nothing had been done following the alleged abuse.
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Unfortunately, many Chicago nursing homes are found on the Quarterly Violator List of negligent facilities by the Illinois Department of Public Health. For example, Warren Park Health and Living Center located at the 6700 block of North Damen recently received several Type “A” Violations from the Illinois Department of Public Health and was fined $20,000. The violations were given as a result of negligent care that led to the death of a suicidal resident while taking a bath.

The victim was admitted to the facility earlier this year with several ailments, including bi-polar disorder, chronic obstructive pulmonary disease, and noted suicidal ideation. A few months ago, the resident was found unresponsive in a tub room on the first floor. The woman was laying face up in the tub with the water pouring full blast straight into her mouth. The resident died at a local hospital shortly after.

An investigation into the event revealed the resident had told other employees several times before of her desire to commit suicide. Specifically, she had previously tried to drown herself-only a month before this incident. She was placed on monitoring over those concerns, but that monitoring lapsed.

Overall, the facility did not have any policies and procedures in place to ensure that residents did not have unfettered access to the unsupervised tub room. They did not fill out an appropriate incident report following this accident, nor did they pass along the information to the Regional Health Department as required.
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The Illinois Department of Public Health recently released the latest list of nursing homes found to have violated basic laws concerning resident health, care, and safety. One of those negligent nursing homes, The Westlake Home, recently received several Type “A” Violations from the Illinois Department and fined $20,000. The sanctions resulted from abuse, mistreatment, neglect, and psychological sexual abuse of a vulnerable young resident.

Psychological sexual abuse, more commonly considered sexually assault, involves the unwelcome contact, exposure to sexual language, explicit material, or unwanted advances and gestures. Obviously, this form of abuse is prohibited between residents and staff as well and among residents. However, as is far too common at nursing homes across the state, Westlake failed to protect one resident from the inappropriate sexual advances of another.

State officials discovered one female resident naked in her room. When asked, the resident explained that another male resident had removed her clothes and inappropriately touched her. The male resident told the vulnerable female victim that she needed to be undressed to take a bath. It was then that he exposed himself to her and made sexual contact.

The victim has a very low IQ and is in need of continuous supervision to ensure her safety. Obviously that close care was lacking in this case, as the fellow resident was able to violate the victim while alone. The aggressor was known to have previously exhibited inappropriate sexual advances, yet steps were not taken to ensure other residents were protected from his actions.
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We continue looking at the latest report of Illinois nursing homes that have been found to have violated basic laws concerning resident health, care, and safety. Camelot Terrace, a nursing home in Streator, recently received several Type “A Violations from the Illinois Department of Public Health and fined $25,000. The violations resulted in part from the facility’s failed response to potential abuse

The nursing home’s abuse prevention plan requires that potential abuse of a resident by anyone in any form be reported immediately to the facility’s nursing director and then, subsequent an investigation, the proper legal authorities if necessary. While the nursing director is conducting an investigation into the allegation, steps were supposed to have been taken to ensure that the abuse could not continue. However, state authorities discovered that Camelot Terrace employees failed to follow this vital protocol.

One resident was discovered to have bruising around her thighs, anal area, and perineum-injuries that she did not have the night before. A certified nursing assistant informed the Director Nursing at Camelot Terrace of her concerns about the resident’s family member who was with the resident in the interim, claiming that the family member is “always messing around with her.” The assistant was also concerned that the family member was attempting to move the resident in the improper manner-without a mechanical lift.

Other staff members also reported the resident was clearly scared any time that particular family member came to visit. They also remember additional injuries to the resident any time the family member was around. Later a nursing home employee recalls seeing the man leaving the resident’s room after being in there alone; he was zipping up his sweatshirt and visibly sweating.

As of the issuance of the citation for these issues, the aggressor had still not been contacted, questioned, or additional protection provided to the resident.

For some reason, the clear signs of sexual and or physical abuse at the facility were not considered worthy of more thorough investigation. In all circumstances, a logical, necessary response to the potential crime would have been to contact police officers immediately, seeking treatment and protection for the victim.
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We continue looking at the latest report of Illinois nursing homes that have been found to have violated basic laws concerning resident health, care, and safety. The Alden Alma Nelson Manor, a nursing home in Rockford, recently received several Type “A” Violations from the Illinois Department of Public Health and fined $15,000. The violations resulted from improper emergency responses following the sexual abuse of several nursing home residents.

Specifically, state health officials discovered at least three instances where staff members failed to keep residents from being sexually abused by another resident. The attacking resident had previously been diagnosed with Bipolar disorder and post traumatic stress disorder. He showed clear signs of verbal abuse, physical abuse, and socially inappropriate behavior. Staff members were also aware that the resident’s physical size (over 6 feet tall, weighing roughly 230 pounds) made him an imposing figure to more vulnerable residents.

On at least three occasions members of the staff at the facility caught the resident having inappropriate sexual relations with other residents. However, following none of those incidents did the facility call police or emergency personnel. Instead, they simply talked with the abuser’s probation officer and asked about removing him from the facility.

We continue looking at the latest report of Illinois nursing homes that have been found to have violated basic laws concerning resident health, care, and safety. The University Nursing and Rehabilitation Center in Edwardsville, recently received several Type “A” Violations from the Illinois Department of Public Health and fined $20,000. The violations resulted in part from inadequate supervision of residents known to pose unique risks for falls and injury.

One resident of the facility, a dementia patient, was considered ‘high risk” for falls following an assessment made by nursing home employees. As a result she was placed on a specialized plan that sought to minimize the chance of injury due to his unsteady gait, osteoporosis, and decreased safety awareness.

However, several months ago, the certified nursing aide provided supervision to the resident admitted leaving the vulnerable resident on the side of her bed unattended, sliding one side of the bed rails down. Not long after being left in that position unattended, the resident fell off the bed hitting her head in the process-a large wound was present. But instead of calling emergency personal immediately, the resident was simply put back in bed. Hours later a supervising nurse checked on the resident, noticed that she was suffering problems and called for an ambulance.

The Virgil Calvert Nursing and Rehabilitation Center, a care facility in East St. Louis, recently received several a Type “A” Violations from the Illinois Department of Public Health and fined $40,000. The violations resulted in part from failure to provide proper oversight and not protecting several residents from sexual abuse leading to exposure to sexually transmitted diseases.

The facility admitted one resident who suffers from mild dementia and Alzheimer’s disease. He is partially mentally impaired mentally and was a registered sex offender. The first incident involved the aggressive resident being found with a confused female resident to who claimed not to understand what had just happened.

In other cases, the resident was accused of inappropriately touching several female residents who did not possess the mental capacity to consent to that type of physical contact. Following several of the violations the nursing home employees did not create any sort of nursing or incident report or notify the state regulatory department about the conduct.

Edwardsville Terrace, a care facility in Southern Illinois, recently received several Type “A” Violations from the Illinois Department of Public Health and fined $20,000. The violations resulted from a mismanaged healthcare emergency situation at the facility which involved nursing home abuse and neglect.

A mentally disabled and diabetic resident of the facility had been ill for several weeks. However, staff of the nursing home failed to properly provide close monitoring after the illness, such as recorded daily vital signs. In addition, they did not properly check the resident’s blood-sugar levels. Ultimately, the resident had a severe reaction to a medication, which nursing home staff should have known was going to occur.

Illinois nursing home investigators declared that Edwardsville Terrace staff had been negligent in failing to provide proper oversight of the resident’s illness and developing complications. They should have enacted necessary, systematic check-ups to ensure that the resident received the proper treatment.

The Collinsville Rehabilitation & Health Care Center, afacility in Southern Illinois near St. Louis, recently received several Type “A” Violations from the Illinois Department of Public Health and fined $20,000. The violations resulted from mismanaged situation resulting in one resident sexually abusing another.

One resident at the facility was allowed to attempt sexual assault on another resident on two separate occasions. The abusive resident went up to the victim without her notice while she was leaving a bathroom and pulled up her skirt. The victim immediately told staff members about the situation, but they did nothing. Later, the same resident went back into the victim’s room, held her to her bed, told her to be quiet, and attempted to remove her garments. Luckily, the victim’s screams ultimately scared the man away, and he fled the room.

Records indicated that the man had a history of drug and alcohol abuse, abusive conduct, and mental illnesses. He was admitted to the facility from the U.S. Medical Center for federal prisoners in Springfield, Missouri. The Collinsville facility had failed to perform even a basic background check on the individual before admitting him.

The California Gardens Nursing and Rehab Center, a care facility on the southwest side of Chicago, recently received a Type “A” Violation from the Illinois Department of Public Health and fined $5,000. The violation resulted from mismanaged situations at the facility which involve nursing home neglect.

Contrary to proper procedure, a resident at the facility was allowed to obtain cigarettes and smoke unsupervised in his own bedroom on several occasions. Previously, the resident had burned his chest while smoking on his room while lying down. On subsequent interviews with the resident by investigators, it became clear that the problem had still not been resolved. The resident continued to obtain cigarettes and lighting capabilities.

This particular resident had been diagnosed with major depressive disorder, seizure disorder, cerebral vascular accident-prone, and diabetes. Those vulnerabilities plus the resident’s history of inappropriate smoking, mean that nursing home administrators and staff need to provide extra oversight of the resident to ensure that future violations no longer occur. The smoking presented a hazard to all residents in the facility.

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