Nursing Home Violations for 2017 First Quarter

SPRINGFIELD – The Illinois Department of Public Health (IDPH) today announced the following type “AA” and “A” violations of the Nursing Home Care Act processed during the first quarter of 2017.  An “AA” violation is cited when there is a condition or occurrence at the facility that proximately caused a resident’s death.  An “A” violation pertains to a condition in which there is a substantial probability that death or serious mental or physical harm will result, or has resulted.
 
The Quarterly Report of Nursing Home Violators can be found on IDPH’s website and contains additional information about the violations.
 
January
Alden Lakeland Rehab & Health, a 300-bed skilled care facility located at 820 West Lawrence, Chicago,  has been cited with an “A” violation and fined $25,000 for failure to implement fall prevention monitoring and interventions, resulting in a resident falling numerous times and suffering several injuries.  The facility has requested a hearing.
 
Alden Town Manor Rehab, a 249-bed skilled care facility located at 6120 West Ogden, Cicero, has been cited with an “A” violation and fined $25,000 for failure to notify a resident’s physician about a worsening heart condition leading to hospitalization for gangrene and ultimately the amputation of the resident’s lower leg.  The facility has requested a hearing.
 
Ambassador Nursing & Rehab, a 190-bed skilled care facility located at 4900 North Bernard, Chicago, has been cited with an “A” violation and fined $25,000 for failure to supervise residents for aspiration and to identify a resident choking in the dining room, who later died.  The facility has not yet paid the $25,000 fine.
 
Bria of Belleville, a 140-bed skilled and intermediate care facility located at 150 North 27th Street, Belleville, has been cited with an “A” violation and fined $25,000 for failure to provide antibiotic treatment and treatment for potential dehydration, resulting in the resident being admitted to the hospital with septic shock.  The facility paid $12,500.
 
Gardenview Manor, a 213-bed skilled and intermediate care facility located at 14792 Catlin-Tilton Road, Danville, has been cited with an “AA” violation and fined $50,000 for failure to assess a residents’ risk for falls and implement interventions.  This resulted in a serious fall and the resident sustaining injuries resulting in death.  The facility has not yet paid the $50,000 fine.

Manor Care of Palos Heights West, a 130-bed skilled care facility located at 11860 Southwest Highway, Palos Heights, has been cited with an “A” violation and fined $25,000 for failure to use two people when transferring a resident, resulting in the resident being injured and requiring surgery.  The facility has requested a hearing.
 
Nokomis Rehab & Health, a 92-bed skilled care facility located at 505 Stevens Street, Nokomis, has been cited with an “A” violation and fined $25,000 for failure to implement procedures to prevent a resident from pulling out a tracheostomy tube, resulting in asphyxiation and death.  The facility has not yet paid the $25,000 fine.
 
Sharon Health Care Elms, a 98-bed skilled care facility located at 3611 North Rochelle, Peoria, has been cited with an “A” violation and fined $25,000 for failure to properly move a resident, resulting in the resident sustaining multiple injuries.  The facility paid $12,500.
 
Timbercreek Rehab, a 202-bed skilled care facility located at 2220 State Street, Pekin, has been cited with an “A” violation and fined $25,000 for failure to safely transfer a resident from the bed to a wheelchair, resulting in the resident sustaining broken fingers.  The facility also failed to thoroughly investigate and report the incident to IDPH, and assess the risk of entrapment for residents due to bed rails.  The facility has not yet paid the $25,000 fine.
 
February
 
Aviston Countryside Manor, a 97-bed skilled and intermediate care facility located at 450 West 1st Street, Aviston, has been cited with an “A” violation and fined $25,000 for failure to safely transfer a resident and prevent a fall, resulting in the resident sustaining a broken leg.  The facility waived its right to a hearing and paid $16,250.
 
Citadel Care Center-Kankakee, a 107-bed skilled care facility located at 900 West River Place, Kankakee, has been cited with an “A” violation and fined $25,000 for failure to notify the physician of a significant change in a resident’s condition, resulting in seizures and hospital admission to the intensive care unit.  The facility has requested a hearing.
 
Citadel Estates Hazel Crest, a 64-bed shelter care facility located at 3701 West 183rd Street, Hazel Crest, has been cited with an “A” violation and fined $12,500 for failure to have guidelines to assess the risk of injury to residents while being physically transferred, resulting in a resident falling and sustaining an injury that resulted in death.  The facility has requested a hearing.
 
Kanthak House, a 16-bed intermediate care facility for the developmentally disabled located at 724 Second Avenue, Ottawa, has been cited with an “A” violation and fined $6,250 for failure to follow its own policies and procedures for preparation of meals and supervision of residents with known special eating needs, resulting in one resident choking.  The facility paid $6,250.

Rosewood Care Center Edwardsville, a 120-bed skilled care facility located at 6277 Center Grove Road, Edwardsville, has been cited with an “A” violation and fined $25,000 for failure to safely transfer a resident, resulting in the death of the resident due to a fall from a mechanical lift.  The facility has requested a hearing.
 
Winning Wheels, an 88-bed skilled care facility located at 701 East 3rd Street, Prophetstown, has been cited with an “A” violation and fined $25,000 for failure to protect a resident who was hit by a staff member.  The facility is paying $16,250. 
 
 
March
Aperion Care Jacksonville, a 113-bed skilled care facility located at 1021 North Church Street, Jacksonville, has been cited with an “A” violation and fined $25,000 for failure to follow its policies and procedures, which resulted in a mentally ill resident hitting another resident and staff member, being arrested by police, and allowed to leave the facilities without treatment and against medical advice.  The facility has requested a hearing.
 
Arthur Home, The, a 53-bed skilled care facility located at 423 Eberhardt Drive, Arthur, has been cited with an “A” violation and fined $25,000 for failure to follow its abuse prevention policy and fully investigate an allegation of employee abuse, resulting in a resident being exposed to an allegedly abusive employee for seven additional days.  The facility has requested a hearing.
 
Brother James Court, a 99-bed intermediate care facility for the developmentally disabled located at 2508 St. James Road, Springfield, has been cited with an “A” violation and fined $10,000 for failure to ensure adequate nursing staff, nursing assessment, patient monitoring, and notification of a medical emergency, resulting in two residents developing pneumonia and being hospitalized.  The facility has requested a hearing.
 
Danville Care Center, a 20-bed skilled and intermediate care facility located at 1701 North Bowman, Danville, has been cited with an “AA” violation and fined $50,000 for failure to honor a resident’s Advanced Directive and provide cardiopulmonary resuscitation when the resident was found unresponsive.  The facility has requested a hearing.
 

Frankfort Healthcare and Rehab Center, a 57-bed skilled and intermediate care facility located at 2500 East St. Louis Street, West Frankfort, has been cited with an “A” violation and fined $25,000 for failure to address a resident’s adverse reaction to a room change, leading to injection of psychotropic medication and a subsequent fall, resulting in the resident suffering a brain hemorrhage.  The facility waived its right to a hearing and paid $16,250.
 
Gibson Community Hospital Annex, a 26-bed skilled care facility located at 430 East 19th, Gibson City, has been cited with an “A” violation and fined $25,000 for failure to safely transfer a resident at risk for falls, resulting in the resident falling and breaking both an arm and leg.  The facility waived its right to a hearing and paid $16,250.
 
Heartland of Galesburg, a 84-bed skilled care facility located at 280 East Losey Street, Galesburg, has been cited with an “AA” violation and fined $50,000 for failure to ensure staff know when to perform cardiopulmonary resuscitation and provide a change in status assessment, resulting in a resident not receiving cardiopulmonary resuscitation when suffering respiratory arrest.  The facility has requested a hearing.
 
Jerseyville Nursing and Rehab Center, an 111-bed skilled care facility located at 1001 South State Street, Jerseyville, has been cited with an “A” violation and fined $25,000 for failure to prevent a resident falling from a wheelchair.  The resident sustained multiple serious injuries.  The facility waived its right to a hearing and paid $16,250.
 
Pearl Pavilion, a 109-bed skilled care facility located at 900 South Kiwanis Drive, Freeport, has been cited with an “A” violation and fined $25,000 for failure to supervise a resident at risk for falls and evaluate the effectiveness of the fall prevention interventions, resulting in the resident falling and suffering a fatal injury.  The facility has requested a hearing.
 
Renaissance Care Center, a 120-bed skilled care facility located at 1675 East Ash Street, Canton, has been cited with an “A” violation and fined $25,000 for failure to keep a resident from falling during a bed linen change, resulting in the resident suffering serious injuries.  The facility has requested a hearing.
 
Rosewood Care Center - Edwardsville, a120-bed skilled care facility located at 6277 Center Grove Road, Edwardsville, has been cited with an “A” violation and fined $25,000 for failure to provide supervision to prevent falls, resulting in one resident falling and suffering serious injuries.  The facility has requested a hearing.
 
Sharon Health Care Pines, a 116-bed skilled care facility located at 3614 North Rochelle, Peoria, has been cited with an “A” violation and fined $25,000 for failure to follow its policy to ensure correct diets for residents, resulting in a resident choking and requiring hospitalization.  The facility has requested a hearing.
 
West Suburban Nursing and Rehab Center, a 259-bed skilled care facility located at 311 Edgewater Drive, Bloomington, has been cited with an “A” violation and fined $25,000 for failure to prevent verbal and physical abuse of two residents by a staff member.  The facility has not yet requested a waiver or hearing.
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