Description of research done – overview:
Reviewed IDPH Nursing Home Violations Quarterly reports for the period of 2008-2018, starting with the most recent first, for each of Extended Care Clinical (EEC), LLC’s 14 Illinois locations. Additional Illinois facilities owned by William “Avi” Rothner, and Eric Rothner were also included in this research.
A listing of ECC’s locations can be seen here:
http://extendedcarellc.com/media/pdf/ECC-Facilities_Map-2016.pdf
The IDPH Nursing Home Violations Quarterly reports can be found here:
http://www.dph.illinois.gov/topics-services/health-care-regulation/nursing-homes/violator-quarterly-reports
2018 – 1st Quarter
Grasmere Place
Survey Date – 11/01/2017
A fine of $12, 500.00
DOCKET NUMBER:NH 18-C0010
http://dph.illinois.gov/sites/default/files/publications/NH18-C0010-11-01-17-GrasmerePlace.pdf
The facility failed to follow the drug test policy and conduct a drug test, carry out physician orders regarding care, medications. They also failed to follow CPR policy and standards to provide effective CPR, and provide psychiatric rehab services. The facility director of nursing failed to review physician’s orders for one resident and failed to provide prenatal care for 2 pregnant women. Failures contributed to fetal demise of unborn child and overdose resulting in death of the pregnant resident. It was noted that failure to provide effective CPR has the potential to affect all 178 residents. CPR was done on a patient who was sitting on a toilet, rather than moving the patient to a flat surface.
2017 – 1st Quarter
Elmwood Care
Survey Date: 01/2016
Violation Amended/Affirmed, Fine Assessment Reduced and/or Notice of Conditional License Withdrawn
DOCKET NUMBER: NH 16-S0069
No information on incident available
2017 – 2nd Quarter
None
2017 – 3rd Quarter
Chateau Nursing & Rehab
Survey Date – 07/27/2017
A fine of $2,200.00.
DOCKET NUMBER: NH 17-S0367
http://dph.illinois.gov/sites/default/files/publications/NH-17-S0367-07-27-17-Chateau-Nrsh-%26-Rehab-Center-102317.pdf
Facility failed to follow fall prevention policy and to supervise and monitor residents. Facility also failed to notify resident’s physician of the severe pain followed by the accident. Resident had sustained neck fractures due to lack of supervision. There was also a resident with fractured humerus who complained about pain for 5 days straight and nursing staff failed to let a doctor know. Another resident had a laceration in the back of head after a fall. Resident had no floor mats in bedroom despite the extensive history of falls. Resident with seven prior documented falls was found under the sink with a laceration to the head.
Timber Point Health Care Center
Survey Date: 06/22/2017
A fine of 2,200.00
DOCKET NUMBER: NH 17-C0332
http://dph.illinois.gov/sites/default/files/publications/NH-17-C0332-06-22-17-Timber-Point-Healthcare-Center-102317.pdf
The facility failed to provide the physician ordered scheduled medication for a resident. This failure resulted in the resident having increased negative behaviors, increased nervousness, and an altered mental state. This required emergency treatment for drug withdrawal. Medication Administration Record dated from 5/1/17 to 6/19/17 indicates that the resident did not receive scheduled doses of medication from 6/4/17 to 6/13/17 and 5/1/17 through 5/4/17 because facility was out of the medication. The resident was prescribed Ativan, to be taken every 8 hours. Staff failed to dispense the medication, and the facility ran out of the medication on several occasions. This resulted in agitation and altered mental state, as well as withdrawal from benzodiazepine.
2017 – 4th Quarter
Chateau Nursing & Rehab
Survey Date- 10/18/2017
A fine of $25,000.000.
DOCKET NUMBER: NH 17-C0515
http://dph.illinois.gov/sites/default/files/publications/NH17-C0515-10-18-17-Chateau-Nrsg%26RehabCtr.pdf
Facility failed to follow fall prevention policies and to supervise high risk patient for falls. This resulted in a resident sustaining lacerations and abrasions to the right forehead and cheekbone. He also had a tear above the right eyebrow and underwent spinal surgery. The same resident had multiple falls and injuries due to inadequate fall prevention policies and precautions. Resident fell of the bed and sustained 2 skin tears to the right arm, measuring 5.0 centimeters and 1.0 cm long. An MRI scan showed that resident had a spinal cord injury at the level of C3,C4, and C5 with unstable fractures to the anterior and posterior columns. On October 17, 2017, the neurosurgeon who saw the resident through the ER said resident had swelling in the neck, spinal cord, and bones and these were not from old injuries. The neurosurgeon stated that the resident should have been sent to the hospital after the first fall that happened in the facility. Resident’s motor skills were highly affected as a result of the fall and spinal injury from the fall, including resident’s ability to open and close mouth, which affected ability to eat.
Generations at Neighbors
Survey Date: 10/26/2017
A fine of 2,200.00
DOCKET NUMBER: NH 17-S0558
http://dph.illinois.gov/sites/default/files/publications/NH17-S0558-10-26-17-Generations-atNeighbors.pdf
Facility failed to respond to a patient’s medication request. This resulted in the resident experiencing pain, insomnia, and crying. Woman was alert and began crying when talking about her experiences in the past weekend as she explained how the facility ran out of her pain medication. The woman explained they ran out of morphine for the second time in a couple of months and how it has been a nightmare. She explains being up all night and experiencing excruciating pain as well as depression. Records indicate that resident’s physician was not notified when morphine supply ran out. Documentation indicates multiple times when dosage of morphine was not given to resident.
Wheaton Care Center
Survey Date- 08/31/2017
A fine of $2,200.00.
DOCKET NUMBER: NH 17-S0441
http://dph.illinois.gov/sites/default/files/publications/NH17-S0441-08-31-17-Wheaton-CareCenter.pdf
Kitchen staff used a propane gas grill inside the kitchen of the facility because the facility had the gas temporarily shut off and this impeded the facility’s ability to provide residents with hot meals. Using the propane grill indoors in an unvented area could have had the potential to cause a fire and put all the residents at risk. The manufacturer of the propane tank stated that the propane tank should not be used indoors.
The facility also failed to ensure that the dietetic service supervisor was qualified for his position. The supervisor had not completed a Dietary Managers Association or approved managers course. Records indicated he had not completed a 90 hour dietary managers course.
2016 – 1st Quarter
Elmwood Care
Survey Date: 01/21/2016
A fine of 2,200.00
DOCKET NUMBER: NH 16-S0069
No information available on incident.
2016 – 2nd Quarter
None
2016 – 3rd Quarter
None
2016 – 4th Quarter
Briar Place
Survey Date: 08/31/2016
A fine of 2,200.00
DOCKET NUMBER: NH 16-S0458
http://dph.illinois.gov/sites/default/files/publications/NH16-S0458-08-31-16-BriarPlace-010917.pdf
There was neglect and failure to observe a resident. The tub room was unsupervised and the resident was found undressed, floating face down in the tub. There was also blood in the water streaming from the mouth and resident was unresponsive. Blood was coming out of the resident’s nose during compressions. The resident was later pronounced dead at the facility. The resident was to shower 2x’s a week with supervision until the next review. However, a resident stated that there were no locks on any shower/tub rooms at any time of the day. Additionally, staff would occasionally check tubs/showers, but didn’t check all the time. Similarly, another resident states that he gets his own linens from the linen room even though he’s not supposed to because the nurses are busy. Moreover, he states staff has never checked on him when he’s bathing.
Countryside Nursing and Rehab Center
Survey Date: 09/21/2016
A fine of $25,000.00
DOCKET NUMBER: NH 16-C0483
http://dph.illinois.gov/sites/default/files/publications/NH16-C0483-09-21-16-Countryside-Nrsg&RehabCtr-010917.pdf
They failed to demonstrate adequate supervision to a patient with dementia wandering into another resident’s room. This resulted in a resident being physically assaulted. A resident went into another resident’s room where resident 1 became aggressive, hitting the other resident in the mouth. There was scratches on the back, neck, and breast of the resident who was sexually assaulted.
2015 – 1st Quarter
The Estates of Hyde Park
Survey date 2/09/15
A fine of $2,200.00
DOCKET NUMBER: NH 15-C0116
http://www.dph.illinois.gov/sites/default/files/resources/NH15-C0116-2-9-15-Estates-of-HydePark.pdf
Failure to provide adequate fall prevention policies. A resident was found on the floor with multiple skin tears. Another resident required 2 people for mobility and was only seeing 1 person each time. Also, the bed had no rails. Resident fell against the radiator cover causing the cover to become dislodged and this resulted in multiple skin tears. The resident also had a bed alarm in place but it did not alarm. Another resident was receiving incontinence care by only one CNA when instructions in the MDS specifically indicated a two person assistance for bed mobility.
Prairie Manor Nursing Home and Rehab Center
Survey Date: 12/14/14
A fine of $2,200.00
DOCKET NUMBER : NH-15C0006
http://www.dph.illinois.gov/sites/default/files/resources/NH15-C0006-121414-Prairie-Manor-Nsg-and-Rehab.pdf
The facility failed to perform a proper and safe mechanical lift for 3 or 4 residents. The lack of adequate precautions resulted in slipping and sustaining a fractured arm for a resident. The nurse aide reported performing the transfer by herself when it should have been completed by two, consequently, the resident started complaining of left shoulder pain. The physician stated that the resident fractured her left arm during the transfer earlier that day, but did not receive a call from the nurse until later that night.
Grasmere Place
Survey date: 1/1/15/15
DOCKET NUMBER: NH 15-C0040, NH 15-S0041
http://www.dph.illinois.gov/sites/default/files/resources/NH15-C0040-S0041-1-15-15-Grasmere-Place.pdf
Staff failed to follow policies and procedures for infection control. The facility failed to properly sanitize blood glucose equipment. They failed to remove expired stock medication, expired medications, and medication of discharged patients, posing a great risk. There was also failure to take temperature of the food and recording it. Failure to record proper food temperature can result in uncooked food or foodborne-illness. There was also pots and pans washed improperly with food residue. The call system was faulty, having pull cords higher than 6 inches from the floor.
2015 – 2nd Quarter
The Estates of Hyde Park
Survey Date: 4/14/15
No Fine
DOCKET NUMBER: NH-15S0201
http://www.idph.state.il.us/about/nursing_homes_violations15/2nd_Quarter/15-S0201%20NH%204-15-15%20Estates%20of%20Hyde%20Park.pdf
The facility failed to provide water at a temperature of at least 100 degrees Fahrenheit at all times for residents.
2015 – 3rd Quarter
Grasmere Place
Survey Date: 8/5/15
No fine
DOCKET NUMBER: 15-C0357
No information on the incident available
Timber Point Health Care Center
Survey Date: 6/25/2015
No Fine
Docket Number: 15-S0316
http://www.dph.illinois.gov/sites/default/files/publications/Nursing_Home_Quarterly_Reports/2015_Q3/15-S0316%20NH%20Timber%20Point%20Healthcare%20Center%206-25-15.pdf
The facility failed to report a fall and the resident had an injury to the head and a broken leg.
Tri-State Nursing & Rehab Center
Survey Date:
No fine
DOCKET NUMBER: 15-S0303
http://www.dph.illinois.gov/sites/default/files/publications/Nursing_Home_Quarterly_Reports/2015_Q3/15-S0303%20NH%20Tri-State%20Nursing%20%26%20Rehab%20Ctr%206-4-15.pdf
Facility failed to perform a safe mechanical lift transfer, resulting in a left forearm wedged underneath the wheelchair armrest while being raised by the lift, caused a laceration of 5 cm and 1.5 cm deep.
2015 – 4th Quarter
Tri-State Nursing & Rehab Center
Survey Date: 06/04/2015
Violation Amended/Affirmed, Fine Assessment Reduced and/or Notice of Conditional License Withdrawn.
DOCKET NUMBER: NH 15-S0303
No information on incident available
Rainbow Beach Care Center
Survey Date: 09/08/2015
No fine
DOCKET NUMBER: NH 15-C0429
http://dph.illinois.gov/sites/default/files/publications/NH15-C0429-09-08-15-Rainbow-Beach-Care-Center.PDF
Multiple patients were given inadequate individualized treatment plans for serious mental illness.
2014 – 1st Quarter
Chateau Nursing & Rehab Center
Survey Date: N/A
DOCKET NUMBER: NH 13-G0120
FINAL ORDER – Violation Amended/Affirmed, Fine Assessment Reduced and/or Notice of Conditional License Withdrawn.
No information on incident available
Rainbow Beach Care Center
Survey Date: NA
FINAL ORDER- Violation Amended/Affirmed, Fine Assessment Reduced and/or Notice of Conditional License Withdrawn.
DOCKET #: NH 12-S0012
No information on incident available
Rainbow Beach Care Center
Survey Date: N/A
FINAL ORDER- Violation Amended/Affirmed, Fine Assessment Reduced and/or Notice of Conditional License Withdrawn.
DOCKET #: NH 10-O0076 NH 10-C0207
No information on incident available
Sheridan Shores Care & Rehabilitation Center
Survey Date: N/A
DOCKET #: NH 11-S0212
Violation Amended/Affirmed, Fine Assessment Reduced and/or Notice of Conditional License Withdrawn.
No information on incident available
2014 – 2nd Quarter
Briar Place
Survey Date: N/A
DOCKET NUMBER: NH 10-S0331
FINAL ORDER- Violation Amended/Affirmed, Fine Assessment Reduced and/or Notice of Conditional License Withdrawn.
No information on incident available
Countryside Nursing and Rehab
Survey Date: 4/4/2014
A fine of $25,000.00
DOCKET NUMBER: NH 14-S0190
http://www.idph.state.il.us/about/nursing_homes_violations14/2nd_Quarter/NH%2014-S0190%20Countryside%20Nursing%20and%20Rehab%20Center%204-4-2014.pdf
The facility failed to provide adequate supervision for 3 residents. The lack of supervision resulted in falls and injuries. On resident had to receive 10 staples on the head, another received 3 staples to the eyebrow, and the last one received 2 staples to the head. The resident was being transported to a van by a staff member and as the van exited the road onto a ramp, two residents had their wheelchairs flip over and fell to the left. The resident sustained a laceration to the left side of his head and was immediately rushed to the hospital, where he received 10 staples to the head and 2 sutures. The hospital cat scan revealed a right temporal parietal craniotomy with surgical clips but the facility did not provide documentation. The second resident stated standing in her room and falling,hitting her head, bleeding, and complaining of pain in the right brow area. A third resident raised his head and hit it on the bed frame causing bleeding and the need for 2 staples on the left side of his head. Additionally, his care plan does not indicate wearing a a soft helmet for his jerky moments due to his condition.
South Suburban Rehabilitation Center, LLC
Survey Date: N/A
DOCKET NUMBER: NH 14-S0019
FINAL ORDER – Violation Amended/Affirmed, Fine Assessment Reduced and/or Notice of Conditional License Withdrawn.
No information on incident available
St. James Wellness Rehab Villas
Survey Date: 5/13/2014
A fine of $2,200.00
DOCKET NUMBER: NH 14-C0234
http://www.idph.state.il.us/about/nursing_homes_violations14/2nd_Quarter/NH%2014-C0234%20St%20James%20Wellness%20Rehab%20Villas%205-13-2014.pdf
Failure to use gait belt during the transfer of a resident resulted in a fracture to the right arm. There was also failure to use the gait belt for other residents who were reviewed for assistance of activities of daily living. A CNA was moving a resident from her bed to a shower chair in the bedroom and while doing the transfer without a gait belt and lifting her from the arms, she heard a pop sound from the residents right shoulder. A radiology report started the resident had acute comminuted and displaced fracture of the proximal humerus through the surgical neck. The restorative director stated that gait belf must be around the waist and staff should not lift resident under the ams. The physical therapy manager also stated that gait belts are universal and should be used by anyone who is being transferred.
2014 – 3rd Quarter
Chateau Nursing and Rehabilitation
Survey Date: N/A
DOCKET NUMBER: NH 13-G110
DOCKET NUMBER: NH 13-G110
FINAL ORDER – Violation Amended/Affirmed, Fine Assessment Reduced and/or Notice of Conditional License Withdrawn
No information on incident available
Greenwood Care
Survey date: n/a
violation Amended/Affirmed, Fine Assessment Reduced and/or Notice of Conditional License Withdrawn.
DOCKET NUMBER: NH 13-G110
No information on the incident available
Tri- State Nursing and Rehab Center
A survey 7/8/14
A fine of 2,200.00
DOCKET NUMBER: NH 14-S0334
http://www.idph.state.il.us/about/nursing_homes_violations14/3rd_Quarter/NH%2014-S0334%207-18-14%20Tri-State%20Nsg%20and%20Rehab.pdf
Facility failed to provide 2 person care while assisting a resident. This resulted in resident falling out of the bed and ended with a hip fracture and hip surgery for a resident.
South Suburban Rehab Center
Survey Date: 8/12/14
A fine of $25,000.00
DOCKET NUMBER: NH 14-C0369
http://www.idph.state.il.us/about/nursing_homes_violations14/3rd_Quarter/NH%2014-C0369%208-12-14%20South%20Suburban%20Rehab%20Center.pdf
A resident fell and was observed with a laceration on the lip after being aggressive and combative against medical staff. However, his medical records have no psychosocial interventions to decrease combative behavior. Similarly, ten other residents who were advised by a psychiatrist to be combative, had no intervention recommendations listed under medical record. Resident lost his balance and hit his head on the headboard but he stated the was hit by the staff. This resulted in a laceration to the upper lip and 3 sutures. The psychiatric physician explained that nobody ever called to let him know of the incident, the arrest of an employee, or facial lacerations, they just spoke to me about consultations and medications. A family member of the resident stated “the boy he was working with hit him in the mouth. My husband has a big piece missing out of his lip, I don’t like this”. The social service director stated that there are no protocols in place when dealing with elderly residents with aggressive behaviors.
2014 – 4th Quarter
St James Wellness Rehab Villas
Survey Date: N/A
DOCKET NUMBER:NH 14-C0234
Final Order: Violation Amended/ Affirmed, Fine Assessment Reduced and/or Notice of Conditional License Withdrawn.
No information on incident available
2013 – 1st Quarter
Tri-State Nursing and Rehabilitation Center
Survey Date: 1/2/13
A fine of $1,100.00
DOCKET #: NH 13-C0040
http://www.idph.state.il.us/about/nursing_homes_violations13/1st_Quarter/NH%2013-C0040%20Tri-State%20N%20and%20R%20Center%201-2-13.pdf
Inadequate observation and review, has resulted in pressure sores. This failure resulted in worsening sacral pressure sores and the development of new skin tears. Skin measure documentation dated 12/4/12 state that the resident had a sacral pressure sore measuring 0.5×0.5×2 cm. On 12/5/12 between 10:40 to 2pm, resident was sitting in a reclining chair and was not turned or repositioned or checked for incontinence, or changed at all during this time. At 2pm, the resident was transferred to their room where the nurse aid removed the brief and it was saturated with urine and full of large loose stool. The dressings to the sacrum and left buttocks were visibly soiled with both moist and dry stool and were falling off the residents skin. The pressure sore was measured and had an increased size of 3×1.4×0.1 cm. The wound care plan stated to keep area clean and dry but did not mention reposition for pressure relief or other interventions for the care and treatment of ulcers. However, physician orders state “turn and reposition every 2 hours, every shift as needed”. Additionally, resident was observed with wound to the left upper thigh, however, there was no documentation or Branden Assessments done. The nursing aides could not tell when the wound appeared or if it was getting worse.
2013 – 2nd Quarter
Prairie Manor Nursing & Rehab Center
Survey Date: 5/10/13
A fine of $2,200.00
DOCKET #: NH 13-C0244
http://www.idph.state.il.us/about/nursing_homes_violations13/2nd_Quarter/NH%2013-C0244%20Prairie%20Manor%20Nursing%20and%20Rehab%20Center%205-10-13.pdf
Failure to establish preventative measures from eloping. A resident eloped and resulted in sustained a fracture while he was away from the facility. The resident was taken to the emergency room where he was found, confused, skin cold to touch, clothes completely covered in water and mud. Resident also had abrasions to both knees and fractured the fibula.
Timber Point Healthcare Center
Survey Date: 4/2/2013
A fine of $25,000.00
DOCKET #: NH 13-S0216
http://www.idph.state.il.us/about/nursing_homes_violations13/2nd_Quarter/NH%2013-S0216%20Timber%20Point%20Healthcare%20Center%204-2-13.pdf
A resident was abused by a staff and the facility failed to establish a resident safe environment. The facility also failed to ensure all staff on how to redirect resident behavior. The facility also failed to report abuse to a resident by staff.
2013 – 3rd Quarter
None
2013 – 4th Quarter
Chateau Nursing & Rehab Center
Survey Date: 9/3/2013
A fine of $2,200.00
http://www.idph.state.il.us/about/nursing_homes_violations13/4th_Quarter/NH%2013-S0466%20Chateau%20Nursing%20&%20Rehab%20Center%209-3-13.pdf
Failed to take effective precautions against falls, especially high risk patients. As a result, a person fell and sustained a displaced fracture to the left hip, and another had a nasal fracture.
2012 – 1st Quarter
Hillcrest Nursing & Rehabilitation Center
Survey Date: 11/15/11
A fine of $31, 600.00
DOCKET #: NH 11-C0417 & NH 11-S0418
http://www.idph.state.il.us/about/nursing_homes_violations12/1st_Quarter/NH%2011-C0417%20and%20NH%2011-S0418%20Hillcrest%20N&RC%2011152011.pdf
The facility failed to prevent 23 residents from verbal, sexual or mental abuse while a high risk offender was in the building. The offender had a history of aggressive and violent behavior. The facility failed to identify this high risk offender and also provide adequate supervision for the residents. A resident was admitted into the facility on 10/03/2006 with an extensive history of aggressive and threatening behaviors to residents and staff. However, the Criminal History Analysis Report (CHAR) was not completed until 8/3/11, after a peer was sexually assaulted. The CHAR assessed the resident as a HIGH RISK identified offender. Recommendations included close monitoring for behavior or symptom changes and a single room with close proximity to the nurses station. However, this person was admitted to a room with roommate and then transferred to another room with another roommate.The resident was accused of sexually abusing multiple residents. Residents state “he made me have sex with him even though I didn’t want to”, “everyone is afraid of him”, “he hit me and threatened to kill me if I told anyone”.
Hillcrest Nursing & Rehabilitation Center
Survey Date: 2/3/2012
A fine of $12,500.00
DOCKET #: NH 12-C0059
http://www.idph.state.il.us/about/nursing_homes_violations12/1st_Quarter/NH12-C0059%20Hillcrest%20N&RC%2002032012.pdf
The facility failed to document a resident’s narcotic intake or monitor the antidepressant intake. They failed to ensure the documentation and narcotic control sheet was consistent and accurate. As a result, the resident was found unresponsive, admitted to an ICU, placed on a ventilator and diagnosed with opioid poisoning and later pronounced dead. The medication administration record showed the resident was taking frequent doses of Vicodin 2 tablets each day, however, there was no documentation available for it which was required according to the Director of Nurses. There were also multiple times in which the resident was receiving 3 doses of Vicodin in a 24 hour period, meaning he was taking 45 mg of Hydrocodone and 4500 mg of Tylenol. Recommendations from drugs.com indicate that no person should take more than 4000 mg of Tylenol in 24 hours and the resident was receiving more than this on most days. Additionally, a person should not take more than 5 tables of Vicodin and he was taking 6 on mos days. There was no documentation or follow-up with a pharmacist and huge discrepancies between the medication administration record and controlled substance proof of use sheets. The medical history reported that the resident was also allergic to Tylenol and the monthly pharmacy medication regimen showed there was only no irrefulatries but didn’t mention a tylenol allergy.
Hillcrest Nursing & Rehabilitation Center
Survey Date: 2/7/12 and 3/12/ 2012
A fine of $50,000.00
DOCKET #: NH 12-C0075
http://www.idph.state.il.us/about/nursing_homes_violations12/1st_Quarter/NH12-C0075%20Hillcrest%20N&RC%2002072012.pdf
The facility failed to conduct a comprehensive assessment of the resident, monitor the resident, and have an environment free of hazards. The facility staff found the resident unresponsive (dead) with a long coaxial cord wrapped around her neck and between her jaws. There were 3 burnt pipes above the bed light fixture in the room, one of them was a glass pipe, and the other 2 were metal like that of a broke tv antenna. The pipes had burnt residue in them which was suspected to be drug paraphernalia as suspected by a cop. The nursing aide stated her job was to go up and down the hall to document if she saw any abnormal behavior such as smoking, and drinking alcohol, but never to go into the rooms and check on the residents. Additionally, one hall monitor said “my job is not to help with resident care, pass trays, feed, or monitor smoking. However we assist the CNAs if needed. The round documentation sheet is missing from 00:00 to 7:00 hours which is around the time when the resident was found with the cord wrapped around the neck.
2012 – 2nd Quarter
Hillcrest Nursing & Rehabilitation Center
Survey date: 11-15-11, 2-3-12, & 2-7-12 On
sent Notice of License Revocation. A hearing has been requested.
DOCKET #: NH 12-o0122
No information on the incident
Hillcrest Nursing & Rehabilitation Center
Survey Date: 4/6/2012
A fine of $1,100.00
DOCKET #: NH 12-C0227
http://www.idph.state.il.us/about/nursing_homes_violations12/2nd_Quarter/NH%2012-C0227%20Hillcrest%20N&RC%2004062012.pdf
The facility failed to provide care and services to a resident in a timely matter. They didn’t administer the medication as ordered by the physician. They failed to monitor the resident with critically high blood coagulation. As a result, the resident was found unresponsive in her bed.
Hillcrest Nursing & Rehabilitation Center
Survey Date: 3/12/12
A fine of $1,100.00
DOCKET #: NH 12-S0158
http://www.idph.state.il.us/about/nursing_homes_violations12/2nd_Quarter/NH%2012-S0158%20Hillcrest%20N&RC%2003212012.pdf
They failed to access, obtain physician orders, and follow policies to ensure proper care of a suprapubic catheter or review for bladder infection. This caused the resident to have excruciating pain and to be sent to a hospital.
St. James Manor and Villas
Survey Date: 2/29/12
A fine of $2,200.00
DOCKET #: NH 12-C0143
http://www.idph.state.il.us/about/nursing_homes_violations12/2nd_Quarter/NH%2012-C0143%20St%20James%20Manor%20and%20Villa%2002292012.pdf
Inadequate assessment and documentation of patient hip replacement surgery, resulted in infection to the surgical wound. The resident was admitted into a hospital with a diagnosis of recurrent left hip dislocation and during this time they had a left hip replacement surgery performed. Nursing documentation on admission does not show thorough assessment of left hip surgical site. On 1/25/12 a wound doctor assessed the would and noted pain, redness, and serosanguinous drainage. However, there is no other documentation until 1/28/12, stating the patient is complaining of pain, is weak and the patient’s urine is brown. The patient started complaining of pain during urination and was sent to the hospital and was also found with foul smelling drainage. The failure to provide adequate care resulted in the patient getting sepsis syndrome.
Wheaton Care Center
Survey Date: 10/28/11
By Final Order, Violation Amended and Fine Assessment Reduced.
DOCKET #: NH 11-S0372
http://www.idph.state.il.us/about/nursing_homes_violations11/4th_Quarter/NH%2011-S0372%20Wheaton%20CC%2010-28-2011.pdf
Multiple violations including lack of access to a private telephone, failing to accommodate residents by providing personal razors or incontinence products, lack of appropriate monitoring of patients.
2012 – 3rd quarter
Chateau Nursing and Rehabilitation Center
Survey date: 8/5/12
A fine of $1,100
DOCKET #: NH 12-S0384
http://www.idph.state.il.us/about/nursing_homes_violations12/3rd_Quarter/NH%2012-S0384%20Chateau%20Nrsg%20and%20Rehab%20Ctr%2008152012.pdf
Failed to provide adequate fall prevention for a resident. The resident fell and it resulted in a right hip fracture and laceration to the bilateral knee and right lower leg.
2012 – 4th quarter
None
2011 – 1st quarter
None
2011 – 2nd quarter
Rainbow Beach Care Center
Survey Date:N/A
Final Order, Violation Affirmed, FIne Assessment Reduced and Notice of Conditional License Withdrawn
DOCKET #: NH 09-S0280
No information on the incident available
Timber Point Healthcare Center
Survey Date:n/a
By Final Order, Violation Affirmed, Fine Assessment Reduced and Notice of Conditional License Withdrawn.
DOCKET #; NH 10-S0319
No information on the incident available
2011 – 3rd quarter
Rainbow Beach Care Center
Survey Date: 9/9/2011
A fine of $13,600.00
DOCKET #: NH 11-S0226
http://www.idph.state.il.us/about/nursing_homes_violations11/3rd_Quarter/Rainbow%2011-S0226.pdf
The facility failed to identify sexual abuse within the facility. A resident was fondled and penetrated by another resident.
2011- 4th quarter
South Suburban Rehab Center
Survey Date: 11/2/2011
A fine of $1,100.00
DOCKET #: NH 11-C0317
http://www.idph.state.il.us/about/nursing_homes_violations11/4th_Quarter/NH%2011-C0317%20South%20Suburban%20Rehab%20Center%2009-21-2011.pdf
The resident failed to prevent an accident for a resident. The failure to supervise the resident resulted in rolling out of the bed and sustaining a laceration to the upper brow, requiring 8 sutures.
Wheaton Care Center
Survey Date: 12/1/2011
A fine of $1,100.00
DOCKET #: NH 11-S0372
http://www.idph.state.il.us/about/nursing_homes_violations11/4th_Quarter/NH%2011-S0372%20Wheaton%20CC%2010-28-2011.pdf
Residents do not have access to a private phone were they cannot be overhead. This has the potential to affect all 110 residents in the facility.
2010 – 1st Quarter
Park House
Survey Date: 1/8/2010
A fine of $20,000.00
DOCKET #: NH 09-S0304
http://www.idph.state.il.us/about/nursing_homes_violations10/1stQuarter/Park%20House%2009-S0304.pdf
The facility failed to monitor and provide supervision for a resident. As a result, the resident was found unresponsive in whirlpool tub by staff and pronounced dead in a hospital because of drowning. There was a huge discrepancy of the policy regarding tub rooms. Multiple CNAs stated the tub rooms are always locked while others argued they are kept unlocked because residents in that wing are cognizant and capable. However, an administrator from the facility stated there is no policy stating tubs being locked. The care plan noted that the resident was at risk for seizure activity and should be monitored.
2010 – 2nd Quarter
Rainbow Beach Care Center
Survey Date: N/A
Final Order, Violation Affirmed, FIne Assessment Reduced and Notice of Conditional License Withdrawn
DOCKET #: NH 08-C0195
No information on incident available
Rainbow Beach Care Center
Survey Date: 4/22/2010
A fine of $10,000.00
DOCKET #: NH 10-o0076
http://www.idph.state.il.us/about/nursing_homes_violations10/2ndQuarter/Rainbow%2010-o0076.pdf
Facility failed to ensure that a resident is free from physical abuse and resulted in one resident punching another. The resident sustained a fractured nose. The facility failed to monitor and asses aggressive behavior in resident to prevent injury.
Wilson Care
Survey Date: 6/16/2010
A fine of $10,000.00
DOCKET #: NH 10-S0137
http://www.idph.state.il.us/about/nursing_homes_violations10/2ndQuarter/Wilson%2010-S0137.pdf
The facility failed to supervise an agitated residents with physical aggression toward other residents. As a result of this failure, the agitated residents was able to attack another residen by wrapping a cord around a person’s neck and this resulted in a fist fight. One resident was stabbed twice at the back of the neck with a broken glass. The residents state there was no staff monitoring the first floor when the fight happened. Medication administration records indicate that the resident takes Ativan every 6 hours and Haldol every 4 hours as needed by agitation. However, the records also indicate that on the day of the incident, the patient did not receive medication, causing an agitated, physically aggressive state.
2010 – 3rd Quarter
Rainbow Beach Care Center
Survey Date: 8/5/2010
A fine of $10,000.00
DOCKET #: NH 10-C0207
http://www.idph.state.il.us/about/nursing_homes_violations10/3rdQuarter/Rainbow%2010-C0207.pdf
The facility failed to monitor and supervise cognitively impaired residents. The resident was impaired and disorganized. The resident eloped the facility and travels about 25 miles from the facility and was away for over 10 days, facing danger with mental illness. The resident was returned by an ambulance.
2010 – 4th Quarter
Chateau Nursing and Rehab
Survey Date: 11/5/2010
A fine of $6,250
DOCKET #: NH 10-S0304
http://www.idph.state.il.us/about/nursing_homes_violations10/4thQuarter/Chateau%2010-S0304.pdf
The nurses failed to clean and disinfect the glucometers during blood sugar testing.
Timber Point Health Care Center
Survey Date: 12/1/2010
A fine of $6,250.00
DOCKET #: NH 10-S0319
http://www.idph.state.il.us/about/nursing_homes_violations10/4thQuarter/Timber%20Point%2010-S0319.pdf
The facility failed to complete an annual performance review on al CNAs in order to determine needs/weakness to based the 12 hour required inservice training. They also failed to include caring for the cognitively impaired in the training.
2009 – 1st Quarter
Westshire Nursing and Rehab Center
Survey Date: n/a
By Final Order, Violation Affirmed, Fine Assessment Reduced and Notice of Conditional License Withdrawn.
DOCKET #: NH 07-C0102
No information on incident available
Westshire Nursing and Rehab Center
Survey Date: 2/18/2009
A fine of $35,000.00
DOCKET #: NH 09-C0028
http://www.idph.state.il.us/about/nursing_homes_violations09/1stQuarter/Westshire%2009-C0028.pdf
They failed to prevent the development of new pressure sores in 2 residents. They failed to provide education and other services for healing and prevention of pressure sores.
2009 – 2nd Quarter
None
2009- 3rd Quarter
Chateau Nursing and Rehab
Survey Date: 7/24/2009
A fine of $20,000
DOCKET #: NH 09-C0193
http://www.idph.state.il.us/about/nursing_homes_violations09/3rdQuarter/Chateau%2009-C0193.pdf
The facility failed to supervise a male resident who had a history of sexually inappropriate behavior. This resulted in non-consensual sexual abuse of a female resident.
2009 – 4th Quarter
Greenwood Care
Survey Date: N/A
By Final Order, Violation Reduced, Fine Assessment Reduced and Notice of Conditional License Withdrawn.
DOCKET #: NH 07-C0261
No information on incident available
Rainbow Beach Care Center
Survey Date: 11/24/2009
A fine of $5,000.00
DOCKET #: NH 09-S0280
http://www.idph.state.il.us/about/nursing_homes_violations09/4thQuarter/Rainbow_09-S0280.pdf
Facility failed to provide supervision to a resident who had a history of smoking. He caused a fire by his bed and this could have had the potential to affect all residents on the 1st floor.
Wheaton Care Center
Survey Date: 12/9/2009
A fine of $12,000.00
DOCKET #: NH 09-S0291
http://www.idph.state.il.us/about/nursing_homes_violations09/4thQuarter/Wheaton_09-S0291.pdf
The facility failed to provide supervision for a resident who was physically and verbally abusive. This resulted in one resident being hit to the back and another verbally abused.
2008 – 1st Quarter
None
2008 – 2nd Quarter
None
2008- 3rd Quarter
Elmwood Care
Survey Date: 9/2/2008
A fine of $25,000.00
DOCKET #: NH 08-C0220
http://www.idph.state.il.us/about/nursing_homes_violations08/3rd_Quarter/Elmwood%2008-C0220.pdf
The facility failed to order and follow-up on a psychiatric consultation for a resident who had verbalized hopelessness and suicidal thoughts. The resident ended up breaking his dialysis permanent catheter located on his right jugular vein and bled to death. A 53 year old male on dialysis was continuously expressed suicidal thoughts and review of psychology and NP stated that he needed a psych consult. Social services expressed the resident making decision that were not as his best interest and having a hopeless attitude. During an interview, the director of nursing stated that the psych consult had not been done because she felt “this wasnt an emergent situation, despite verbal expression of suicidal thoughts. The resident left a note stating “I tried to tell you that I didn’t want to live on dialysis anymore..”
Rainbow Beach Care Center
Survey Date: 8/15/2008
A fine of $10,000.00
DOCKET #: NH 08-C0195
http://www.idph.state.il.us/about/nursing_homes_violations08/3rd_Quarter/Rainbow%2008-C0195.pdf
The facility failed to initiate an abuse investigation for 5 of 27 residents with allegations of staff-to-resident physical abuse, resident-to-resident physical and sexual abuse. The facility failed to ensure the facility was free from a male resident with a history of inappropriate sexual behavior.
Rainbow Beach Care Center
Survey Date: 9/30/2008
A fine of $10,000.00
DOCKET #: NH 08-C0240
http://www.idph.state.il.us/about/nursing_homes_violations08/3rd_Quarter/Rainbow%2008-C0240.pdf
The facility failed to ensure that a resident with poor survival skills received adequate supervision. He was away from the facility from more than 30 days without the staff knowing about his whereabouts.
2008 – 4th Quarter
Timber Point Healthcare Center
Survey date: N/A
By Final Order, Violation Affirmed, Fine Assessment Reduced and Notice of Conditional License Withdrawn.
DOCKET #: NH 06-C0291
No information on incident available