Illinois Nursing Home Safety Violations & Facility Inspection Findings

Illinois Nursing Home Ratings & Safety Violation Information

According to Medicare.gov, Illinois has 731 nursing homes. While 465 (64%) of these nursing homes rank average or above on the level of care the home provides, the remaining 266 (36%) maintain below average and much below average ratings. This substandard level of care falls below the acceptable rating that Medicare and Medicaid allow.

Many families in Illinois must arrange skilled nursing medical care for their loved one who is growing older, has a physical impairment, or is rehabilitating from a surgical procedure. These families expect that their loved one will receive the best care in a safe environment. Many staff members in nursing facilities are underpaid, overworked, or lack the necessary training to provide care according to acceptable standards.

Some family members are unaware that their loved one is being victimized through abuse, neglect, or mistreatment until they visit the site and spend time watching the nursing staff and employees perform their duties. Most patients residing in nursing homes are vulnerable to repeated falls, facility-acquired bedsores, physical abuse, scalding, burns, medication errors, or sexual assault by other residents or staff members.

Below is a small sample of the hundreds of violations and citations occurring at nearly all nursing facilities in Illinois. These violations were identified by state surveyors and inspectors investigating opened complaints or when performing annual licensure certifications.

Failure to Protect Residents from All Forms of Abuse

Every nursing facility is duty-bound to protect each resident from all forms of abuse, mistreatment or neglect. Sadly, even though the nursing staff has a responsibility to provide professional care, they are often the guilty suspect of neglect or abuse. Common concerns involving Illinois nursing home abuse protection include:

  • A CNA was told by an LPN to say to the resident that if they did not get up out of bed, they would not get their morning medications (Countryview Care Center – Macomb)
  • The facility did not protect a resident who was verbally abused by a Licensed Practical Nurse (Generations at Lincoln)
  • A resident was not protected from a Certified Nursing Assistant who used verbal abuse toward the resident (Heather Rehab and Health Care Center)
Failure to Protect Residents from Accident Hazards

The nursing home must follow established protocols to create a safe environment and eliminate the potential risk of accidents caused by hazards and dangerous situations. Common problems associated with Illinois nursing homes include:

  • Certified Nursing Aides did not safely transfer a resident that led to an injury (Franklin Grove Living and Rehab Center)
  • The nursing home did not implement behavioral interventions after multiple episodes of a resident’s adverse behaviors (Good Samaritan Society – Geneseo Village)
Failure to Report and Investigate Any Act or Reports of Abuse, Neglect or Mistreatment

If any individual alleges abuse, neglect or mistreatment in the nursing facility, the Administrator and Director of Nursing must begin an immediate investigation and take appropriate measures including reporting the results of the investigation to the State Agency. Any failure to do so can be a violation resulting in a citation or monetary penalty. Concerns involving failures to investigate include:

  • The nursing home did not report an allegation of abuse to the Illinois Department of Public Health (Countryview Care Center – Macomb)
  • The administration did not report an incident of alleged staff-to-resident abuse using standards set by state law (Integrity Health Care of Marion)
Failure to Implement and Follow Infection Protection Protocols

Without taking appropriate measures to protect residents from the spread of infection, the resident’s health can be compromised, and the contagious disease could spread to others in the facility. Serious problems involving infection protection protocols include:

  • The nursing staff did not perform hand hygiene during a wound dressing change (Good Samaritan Society – Geneseo Village, Oak Park Oasis Health Care Center)
  • The facility did not ensure proper disinfection of glucose monitoring devices when used between residents (Meadowbrook Manor – Naperville)
  • The nursing staff did not follow hand hygiene protocol while serving lunch and dinner trays to prevent the spread of infection (Pine Crest Health Care Center)
Failure to Ensure Residents Receive Proper Treatment to Prevent Bedsores

Nearly every facility-acquired bedsore can be prevented if the nursing staff takes appropriate measures and follows established standards of care. Common problems associated with pressure wounds developing in Illinois nursing homes include:

  • The nursing home did not report, assist, or prevent developing bedsores (Franklin Grove Living and Rehab Center)
  • The nursing staff never identified an area of pressure until it evolved into an unstageable bedsore (Generations at Neighbors)
  • The nursing staff never followed its policies to ensure the resident was repositioned every two hours to prevent the development of bedsores (Park View Rehab Center)
  • Nurses never identified a pressure ulcer, prevented a bedsore from worsening, or obtained Physician’s orders for treatment (Rosewood Care Center of Peoria)
Failure to Provide Residents an Environment Free of Unnecessary Physical Restraint

The nursing home cannot use physical restraints unless they are Physician ordered and follow the established standards of protocol and regulations. Serious concerns involving the use of restraint as a convenience or to control the resident that led to a violation, citation or monetary penalty include:

  • The nursing home never completed an assessment before implementing a physical restraint and obtaining consent (Gilman Healthcare Center, Integrity Health Care of Wood River)
  • Restraint policies were not followed, and a restraint was not removed during mealtime. The nursing home never obtained consent (Glenwood Health Care and Rehab Center)
  • Restraint policies were not followed, and consent was not obtained involving a wheelchair seatbelt, bilateral side rails and bilateral bed bolsters (Heather Rehab & Health Care Center)
  • The staff never assessed or reevaluated the use of a bolstered mattress and side rails as restraints and risk for entrapment (Heritage Health – Carlinville)
  • The facility never assessed a resident’s risks versus benefits for using a restraint involving a laptop cushion (Lebanon Care Center)
  • The staff never ensured that a resident with no order for a restraint was free from a restraint when restrained in his wheelchair (Tower Hill Health Care Center)
Other Safety Concerns

Other serious concerns over safety at the nursing facility include the failure to notify the resident’s Physician or family member if there is a significant decline in the resident’s health. Also, problems arise when the resident’s drug regimen has unnecessary medications that could cause harm, injury or death.

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