Nursing Home Spotlight: Pershing Convalescent Home- Berwyn, IL

Pershing Convalescent Home is a small 51 bed nursing home located in Berwyn, IL, a suburb of Chicago.  This nursing home facility received only one out of five stars, which is a much below average rating, according to the government’s Medicare website.

Nursing Home Spotlight: Pershing Convalescent HomeThe facility’s health inspections rated a mere one out of five stars, which is a much below average rating.  In the past year, the nursing home had 14 health deficiencies, which is 6 more than the average number of health deficiencies in Illinois and in the United States.  However, this is an improvement compared to the 30 health deficiencies that the facility received in the previous year. 

Nursing homes must meet strict regulatory standards in order to be certified by Medicare.  Certified nursing homes have an obligation to provide a safe and secure facility for its residents and to provide proper care and supervision to achieve and maintain the highest level of well-being for its residents.

Pressure Sores

One resident who entered the facility with a pressure sore on his ankle did not receive adequate treatment and services in order to promote healing.  This same resident also did not receive adequate services to prevent the development of a new sore on his left heel.

These failures by the nursing home staff pose immediate danger the resident’s health and well-being.  Pressure sores are a serious concern for nursing home residents, especially those with limited mobility due to weakness or illness.  Without proper treatment (cleaning, removal of damaged tissue, dressings, antibiotics), pressure sores can become infected, leading to bone and join infections and even sepsis, which can result in death.

Many residents rely on nursing home staff to provide proper services to prevent pressure sores including turning the resident often enough and pressure reducing mattresses and cushions to help relieve pressure.

Because of the serious nature of pressure sores, nursing home facilities must ensure that a resident who enters the facility without does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable, and a resident having pressure sores must receive necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.  Pershing Convalescent clearly failed to meet this requirement.

Failure to Treat Wounds

According to survey reports, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of its residents by failing to ensure that one resident received proper medical treatment and services to treat wound areas on his right arm.  This resident was completely dependent on staff for bathing and other activities of daily living.

Despite being bathed by staff, staff members failed to notice and therefore failed to treat two open wounds on his arm.  Proper wound treatment is important in elderly nursing home residents because of the risk of infection and further complications.  As such, it is important that staff members be observant to catch injuries and wounds early in order to provide proper treatment.


Nursing home residents have the right to be kept free of physical restraints use for disciplinary purposes or convenience and not required to treat medical symptoms.  However, two residents who did not have physician orders or care plans in place for the use of restraints, were kept in reclining chairs with a lap trays to keep them from getting up.  In order to protect the rights of nursing home residents and prevent abuse, staff members should obtain physician orders for restraints.


Unsanitary Conditions

Nursing home facilities must maintain a sanitary, orderly, and comfortable environment for nursing home residents.  However, recent survey reports verify that Pershing Convalescent failed to meet this requirement because of pungent and pervasive urine and fecal odors that were noted on all three days of the survey.

Upon entering the nursing home facility, inspectors immediately noticed strong urine and fecal odors.  Inspectors continued to notice the odors throughout a tour of the first and second floors.  The pervasive and unpleasant odors do not create a comfortable environment for residents, most of whom are restricted to the interior of the nursing home.


Verbal Abuse

Pershing Convalescent Home failed to report alleged verbal abuse to the Illinois Department of Public Health.  This incident involved a 74 year old female resident who suffered from spinal stenosis (narrowing of the spine that can cause pain), prolapsed bladder (bladder bulges into vagina) depression, and anxiety.  The resident told the administrator and the assistant administrator that one of the nurses was rude and verbally abusive.

When the resident asked for her prescribed medication, the nurse responded, “Go away, get lost.  Get out of my face.  You only want the medication to get high.”  In response to the incident, the administrator suspended the nurse for three days during the investigation.  Although it is facility policy to report abuse to the state licensing agency, the facility never reported the incident to the state agency.

Inadequate Staffing

Pershing Convalescent also failed to provide sufficient staffing for the number of patients at its facility.  Inadequate staffing places patients at risk of harm primarily due to a lack of supervision.

Inadequate staffing is likely responsible for the elopement of a  62-year-old female from the facility.  In response to previously elopement attempts, the woman was placed on high-risk elopement monitoring.  Despite the implementation of high-risk elopement precautions such as: observation flowsheets that provided for visual checks every thirty minutes and a magnet alarm was put in place– the patient still managed to wander from the facility.

Although the resident was located unharmed by the police as she was walking along the side of the street.  The state’s investigation revealed that a staffing deficiency was to blame for the patient’s elopement as one of the CNA’s was late for work.

Making the decision to put a loved one in a nursing home is a difficult decision.  Families should not have the additional burden of worrying about their loved ones suffering from abuse and neglect.  Pershing Convalescent Home has many deficiencies, which calls into question the ability of the facility to provide residents with proper respect, care, and treatment.

For laws related to Illinois nursing homes, look here.


Medicare website

Nursing Homes Abuse Blog: Quarterly Review Of Illinois Nursing Homes Reveals Major Problems 

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