Nursing Home Violations for the Months of November and December

SPRINGFIELD, Ill. – The Illinois Department of Public Health today announced the following type “A” violations of the Nursing Home Care Act were cited during the months of November and December. An “A” violation, which is the most serious licensure violation imposed by the state, pertains to a condition in which there is a substantial probability that death or serious mental or physical harm will result.

The statement of violation for each facility can be viewed by clicking on the facility's name.

Astoria Gardens & Rehab Center, a 69-bed skilled and intermediate care facility located at 1008 E. Broadway, Astoria, has been fined $22,500 for failure to prevent a medication error when staff gave a resident ten times the amount of the ordered dose. Staff also failed to notify the resident’s doctor about the overdose. The resident died two days later. The facility has requested a hearing on the Department’s action.

Bloomington Rehab & Healthcare Center, a 78-bed skilled and intermediate care facility located at 1925 S. Main St., Bloomington, has been fined $10,000 for failure to activate the emergency medical response system. Staff found a resident unresponsive but did not honor an advance directive to resuscitate the resident, who died. The facility requested a hearing on the Department’s action. 

Carroll Co Good Samaritan Center, a 72-bed skilled care facility located at 1006 N. Lowden, Mount Carroll, has been fined $10,000 for failure to supervise a resident and assure the safety of another resident. These failures resulted in the first resident inappropriately touching the other resident. The facility has requested a hearing on the Department’s action. The matter is set for a status conference on June 20. 

Claremont Rehab & Living Center, a 200-bed skilled care facility located at 150 N. Weiland, Buffalo Grove, has been fined $20,000 for failure to supervise a resident at high risk for falls. This failure resulted in the resident suffering a fall, then dying. The facility has requested a hearing on the Department’s action.

The Clayberg, a 49-bed intermediate care facility located at East Monroe Street, Cuba, has been fined $15,000 for failure to assure a resident did not have access to outside doors at the facility that were not monitored or secured. The resident was found uninjured by a staffer. The facility has not requested a hearing on the Department’s action.

Colonial Manor, a 49-bed intermediate care facility for the developmentally disabled located at 300 Church St, Ziegler, has been fined $25,000 for failure to provide comprehensive nursing services for a resident. A change in the resident’s medical condition resulted in death. The facility requested a hearing on the Department’s action. The matter is set for a status conference June 6.

William L. Dawson Nursing Home, a 245-bed skilled care facility located at 3500 S. Giles Ave., Chicago, has been fined $45,000 for failure to prevent neglect. Staff failed to monitor residents in regard to pressure sores, identify new pressure sores, assess and provide treatment for pressure sores and obtain a doctor’s order before treating pressure sores. The facility has requested a hearing on the Department’s action. The case is set for status on June 11. 

Embassy Care Center, a 171-bed skilled and intermediate care facility located at 555 W. Kahler, Wilmington, has been fined $37,500 for failure to supervise residents who were identified or met the criteria of high risk for falls. This failure resulted in several residents suffering falls that required hospital treatments. The facility has requested a hearing on the Department’s action. The matter has been set for status on June 20. 

Evergreen Nursing & Rehab Center, a 120-bed skilled care facility located at 1115 N. Wenthe, Effingham, has been fined $5,000 for failure to follow its policy to protect residents from abuse by employing two staffers with findings of abuse against them. The facility also failed to check references as part of a policy for pre-employment screening. The facility has requested a hearing on the Department’s action. The matter is set for status on June 19.

Friendship Manor, a 97-bed skilled and shelter care facility located at 1209 21 st Avenue, Rock Island, has been fined $7,500 for failure to adequately supervise a resident and prevent elopement. The resident’s monitoring bracelet was removed without all staff being notified. As a result, the resident left the facility, but was found unharmed and returned to the facility. The facility has requested a hearing on the Department’s action. The matter is set for a status conference June 6.

Glenwood Healthcare & Rehab, 184-bed skilled care facility located at 19330 S. Cottage Grove, Glenwood, has been fined $22,500 for failure to ensure each resident at the facility was adequately supervised and monitored to prevent resident to resident abuse. This failure led some residents to fear they could not be protected from a resident who showed aggressive behavior. The facility has requested a hearing on the Department’s action. The matter is set for a status conference May 22.

LaSalle County Nursing Home, a 104-bed intermediate care facility located at 1380 N. 27th Rd., Ottawa, has been fined $15,000 for failure to recognize that two staffers abused a resident when they held down the resident and forced a medical treatment. The resident suffered physical and emotional harm. The facility has requested a hearing on the Department’s action. The matter is set for a status conference June 7.

Lawrence Community Healthcare Center, a 99-bed skilled care facility located at 900 E. Corporation St, Bridgeport, has been fined $10,000 for failure to prohibit food service and housekeeping employees from working while the employees experienced nausea, diarrhea and vomiting before and during a shift. This occurred during an outbreak of gastrointestinal illness that affected residents and staff at the facility. The facility also failed to take proper precaution to prevent the spread of the outbreak. The facility has requested a hearing on the Department’s action. A status in the matter is set for June 18.

Lewis and Clark Manor, a 16-bed intermediate care facility for the developmentally disabled located at 56 Chouteau Trace Parkway, Pontoon Beach, has been fined for failure to ensure the safety of a resident. The resident suffered injury from self-inflicted wounds. The facility also failed to provide residents with nursing services in accordance with their needs. The facility requested a hearing on the Department’s action and paid $22,425 in fines.

Lynhaven, a 16-bed intermediate care facility for developmentally disabled located at 1108 Engineer Rd., Granite City, has been fined for failure to implement its own policies to monitor residents and prevent neglect. As a result, a resident went into a restricted area, fell from a loading dock and later died. The facility requested a hearing on the Department’s action and paid $32,500 in fines.

Manorcare at Elk Grove Village, a 190-bed skilled care facility located at 1920 Nerge Rd, Elk Grove Village, has been fined $5,000 for failure to adequately supervise a resident to prevent them from leaving the facility. Staff mistook the new resident for a visitor and allowed the resident to leave. The facility notified police, who found the resident un-harmed. The facility has requested a hearing on the Department’s action.

Manorcare at Elk Grove Village, a 190-bed skilled care facility located at 1920 Nerge Road, Elk Grove Village, has been fined $22,500 for failure to provide the necessary care and services to a resident who required medication. Staff did not provide medication to the resident for more than two weeks, which led to the resident being hospitalized. The facility requested a hearing on the Department’s action. The matter is set for status on May 23.

Meadowbrook Manor, a 298-bed skilled care facility located at 432 W. Remington Blvd, Bolingbrook, has been fined $20,000 for failure to properly supervise a resident who was smoking while receiving oxygen. This failure resulted in the resident being hospitalized for second and third degree burns. The facility has requested a hearing on the Department’s action. The matter is set for a status conference on June 5.

Pekin Manor, a 120-bed skilled care facility located at 1520 E. Camino Dr, Pekin, has been fined $56,000 for failure to investigate similarities in incidents involving side rails and low air loss mattresses. Residents suffered injuries and one died after being caught between the side rail and mattress. The facility has requested a hearing on the Department’s action.

Provena Cor Mariae Center, a 134-bed skilled and sheltered care facility located at 3330 Maria Linden Dr, Rockford, has been fined $25,000 for failure to ensure a resident received doctor prescribed medications. Instead the resident received another resident’s medications. The facility also failed to properly monitor the resident who later died. The facility has requested a hearing the Department’s action. The matter is set for a status conference on May 24.

Raintree Terrace, a 16-bed intermediate care facility for the developmentally disabled located at 501 E. Chestnut, Carbondale, has been fined $25,000 for failure to implement its policy to prevent neglect; develop and implement monitoring procedures; and investigate, inform and train staff to ensure a resident’s safety. A resident with a long history of PICA, had to be hospitalized after apparently tearing a shirt and eating the threads. The facility has requested a hearing on the Department’s action. The matter is set for status on June 18.

Somerset Place, a 450-bed intermediate care facility located at 5009 N. Sheridan, Chicago, has been fined $20,000 for failure to provide adequate supervision and prevent elopement. A resident who requires supervision was found on the street by police and taken to the hospital with a fractured wrist and forearm. The facility has requested a hearing on the Department’s action.

Tanner Place, a 16-bed intermediate care facility for the developmentally disabled located at 321 Chestnut St, Paris, has been fined $15,000 for failure to implement its system to prevent neglect of a resident with a known history of falls, fractures and injuries. The facility also failed to take sufficient steps to reduce the probability of the resident purposely falling. The facility has requested a hearing on the Department’s action. The matter is set for a status conference on June 11.

Westshire Nursing & Rehabilitation Center, 485-bed skilled and intermediate care facility located at 5825 W. Cermak, Cicero, has been fined $10,000 for failure to provide interventions for a resident who displayed mental and/or psychosocial adjustment difficulty. The resident had multiple episodes of maladaptive behavior including self harm and physical abusive (attention seeking) behavior, but the facility did not come up with a plan to prevent such behavior. The facility has requested a hearing on the Department’s action. The matter is set for a status conference on June 6.