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Illinois Nursing Homes Worst Offenders

Illinois Nursing Homes Worst Offenders

Deciding that a parent or loved one needs to be placed in an elder care facility can be agonizing. Often they don’t want to go, fearing they’re giving up their independence and handing over their fate to unknown nurses and staff at private facilities. And you don’t want to lose their company. But often you have no choice. Even if you want to take care of them, you might be physically unable to, or not have the means to pay for in-home care.

Complicating this difficult life transition is the decision on where to place your loved one. Many nursing homes seem like they’re great places to live, but you’re still taking it on faith that they’ll provide the basic care and comfort your family member deserves -- and you hope above and beyond that. 

The good news is that in our research, we have found that a vast majority of elder care facilities in Illinois have excellent ratings according to Medicare.gov’s nursing home compare tool. The bad news is, some homes do have abysmal track records, including instances of abuse and neglect.

We’ve compiled a list of the nine worst-rated nursing homes in Illinois. We also give examples of some of their worst infractions, so you know what to look for when researching a nursing facility.

[Warning: includes descriptions of severe injuries and medical conditions. Content may be disturbing to some.]

Aperion Care Capitol -- Springfield

Medicare.gov overall rating: N/A (too many deficiencies)

This nursing facility located in the capital of Illinois has been designed as a “Special Focus Facility,” which Medicare.gov says it has a “history of persistent poor quality of care” and is “subjected to more frequent inspections, escalating penalties, and potential termination for Medicare and Medicaid.” 

Chief among the facility’s problems are the many instances of improper pressure ulcer (i.e., bedsore) prevention and treatment. That means residents are sitting in the same spot so long that wounds form on various pressure points on their bodies, like the heels and buttocks. If they aren’t properly cleaned and treated, they can get infected and worsen.

However, even more severe are the two instances of untrained workers tasked to assist with abdominal feeding tubes. In January 2018, a feeding tube became dislodged from a resident’s abdomen. To keep the hole from closing up while they waited for the tube to be replaced, an untrained staff member was instructed to put a (clean) urinary catheter into the spot where the tube was. 

This inexperienced worker must have done it improperly because, over the following week, the resident complained of pain and abdominal distention. The catheter had caused a bowel obstruction, and thus dehydration and severe constipation -- life-threatening conditions for an elderly person. He had to be hospitalized and treated using invasive techniques to repair the damage done.

One major mistake like this is terrible. Yet just two weeks later, another feeding tube mishap took place. A different resident on a feeding tube was sent to the nursing facility. Due to staff not properly checking doctor’s orders, the resident was given far fewer calories than he needed to maintain body weight. He ended up losing roughly 10% of his body weight in just two weeks! Again, another grave life-threatening mistake which could have easily been avoided with proper training and care.

Aperion Care Bloomington -- Bloomington

Medicare.gov overall rating: N/A (too many deficiencies)

Aperion Care’s Bloomington location has also been designated a “Special Focus Facility” for its numerous violations. Its many problems include improper pressure ulcer prevention and care, stolen narcotics medication, improperly administering pain medication, and more. But one of its most egregious screwups was a breakfast scheduling mishap.

Back in 2017, one resident, who has diabetes, had a routine medical procedure that he had to leave the facility very early in the morning. However, his breakfast would show up after he left. For a healthy person, skipping a meal isn’t a big deal, but it can cause dangerous drops in blood sugar for a diabetic. For at least three days, the kitchen sent food to his room, and it returned 15 minutes later untouched because he wasn’t there. Everyone must have shrugged because no one bothered to ensure he was being fed.

On top of that, the resident was on a fluid restriction because of his diabetes, but they must not have received the memo because he was given as much water as he wanted. Further, he was on medication that required him to get a bedtime snack, but -- you guessed it -- he received none.

On September 23, 2017, the resident was found confused and angry the afternoon after skipping breakfast. His blood sugar was at a staggeringly low 23. He was hospitalized and found to have fluid overload, extremely low blood sugar, and another redacted diagnosis. Fortunately, he survived. 

Another diabetic Aperion Care nursing home resident in a different facility died from a blood sugar spike after staff failed to monitor his blood sugar. More on that below. 

On top of all this, the government found his blood sugar and weight had not been adequately tracked -- basic checks that could have revealed the other mishaps well before his need for hospitalization. Due to this series of preventable mistakes, the government deemed these "failures and poor follow-through … neglectful."

Aperion Care Cairo -- Cairo

Medicare.gov overall rating: N/A (too many deficiencies)

Yet another Aperion Care facility, this one in Cairo, and yet another that is designated a “Special Focus Facility.” This one has a long history of some serious violations, including improper bedsore treatment, abuse by staff members, abuse by residents against other residents, and much more. But one horrific incident occurred a few years back.

In early September of 2018, a resident had developed several pressure ulcers on the back, buttocks, and heels. These were so bad the resident was admitted to the hospital for treatment. A week later, he was returned to the nursing facility where his wounds could be monitored. 

And they were -- for a month the nursing staff wrote down the status of his wounds, including the deterioration of the wound on his right heel. The nurse noted increasing pain and an “odor” coming from the wound.

By law, nursing home staff are required to notify the resident’s primary care physician of any change in status. But in this situation, they did nothing. The wound worsened over the course of a month to the point where the resident developed gangrene. Gangrene is an extremely dangerous condition caused by improperly treated injuries. Once it develops, often, the only option is to remove the limb.

And that’s what happened. On October 18, the resident was finally admitted to the emergency room where doctors had to amputate the leg from the knee down to prevent the spread of gangrene. This wasn’t enough as even more of the leg had to be amputated some more before the doctors were satisfied.

Had the nursing home notified the resident’s doctor a month before, they could have saved his leg. Due to their neglect, he wound up an amputee.

Aperion Care Bradley -- Bradley

Medicare.gov overall rating: N/A (too many deficiencies)

And yet another Aperion Care facility makes our hall of shame, this one in Bradley, Illinois. It’s also last in our dubious list to be a “Special Focus Facility” for its ongoing deficiencies, screwups, and neglect.

As with the other Aperion Care facilities, this one has numerous reports for untreated bedsores. Records show that nurses are often aware of serious wounds developing on residents at critical pressure sites, but very little is done for them until it’s too late. Often residents weren’t treated until necrosis (localized skin death) sets in. 

In some cases, like in mid 2019, a resident’s heel sore was never treated and became stage 4, the most serious of bed sores. In stage 4, the wound is so bad that muscle, ligament, and even bone are exposed.

That was the case with this resident’s heel: the bone was exposed and was likely infected -- a life-threatening situation. It was compounded with the fact that the wound was now resistant to many antibiotics. According to the government report, no physician was informed of the wound until it was so advanced. Unfortunately, the report does not mention the fate of the resident.

Aperion Care Moline – East Moline

Medicare.gov overall rating: 1 star (much below average)

The last of the Aperion Care facilities on this list, this one at least managed to eek out a one-star overall rating from Medicare. (We remind readers that any nursing home in the nation can be researched for free on the Medicare Compare site.)

The stories from this facility are just tragic. In November 2017, on a frigid night, an elderly patient was able to walk out of the facility and into the cold night air. According to the subsequent investigation, two different exit alarms failed. By the time police found the man, he was suffering hypothermia. He was found wandering around in gym shorts, no coat, and no shoes. Fortunately, he recovered.

Another resident was not so lucky. On August 11th, a resident was discovered unresponsive and not breathing. Press reports say that no one attempted CPR until EMS arrived. By then, it was too late.

The subsequent investigation revealed the man was found hanging by the rope of his robe. (The belt on the rope apparently got caught on the footboard of his bed and caused accidental strangulation.) His roommate pushed the call button for help, but no one responded for “15 to 20 minutes.” 

When staff did arrive, no attempt was made to revive him, apparently because he had vomited on himself, and no one knew what to do. Despite bringing a crash cart to the room, no one attempted CPR. 

Either one of these stories is tragic in their own right, but the Moline facility has plenty of other violations too, including for bed sores and catheter care.

For a full list of Aperion Care nursing homes, see the end of this post.

South Elgin Rehab & Hcc -- South Elgin

Medicare.gov overall rating: 1 star (much below average)

Our first non-Aperion facility, South Elgin Rehab & Hcc, is the site of a very preventable death of a resident.

According to a government report from February 2018, a resident had sustained a fall during the night (the date of the incident is redacted). An hour later, a nurse on duty administered sedatives due to the resident’s “screaming and agitation”. Four hours later, the resident was found in bed “cold” and unresponsive. 

The staff immediately called 911 and… that’s it. They stayed with the resident but didn’t do anything else.

According to the rules and procedures -- and the resident’s wishes -- CPR-trained staff should have assessed the resident and administered CPR immediately. But it was a long time before someone even took her pulse, let alone performed CPR. 

In fact, they waited until emergency responders showed up and let them do the life-saving procedure. It was all for naught by then. The resident was declared dead within an hour of being found.

It’s difficult to say whether the resident could have been saved by receiving CPR before the emergency responders showed up, but that is beside the point. The staff was required to assess the resident and perform CPR until emergency responders took over, and they didn’t.

Loft Rehab & Nursing Of Normal -- Normal

Medicare.gov overall rating: 1 star (much below average)

Loft Rehab and Nursing of Normal had a not-so-normal complaint filed against them back in March of 2018. One of their residents was too weak to stand up on his own and required a sit-to-stand mechanical device to stand up. A poorly trained staff member attempted to stand the resident up using the device by herself, even though the policy states at least two people are needed to operate the device safely.

As you can guess, the resident fell out of the lift and onto the floor. The fall was bad enough to give him a spiral fracture of the femur. This is an incredibly painful and dangerous break for anyone, let alone an older person. But that’s not the end of the story. The resident was rightfully angry and complaining about the excruciating pain, but the nursing staff simply placed him back in his bed and gave him a Tylenol. 

The government report shows that no one bothered to take the resident to the hospital until the morning, where the fracture was finally discovered and treated. [There is rarely ever a reason for falls within a nursing home and never for bedsores.]

For this dangerous and painful error, Loft Rehab and Nursing of Normal was cited for abuse and neglect.

The Grove Of Berwyn -- Berwyn

Medicare.gov overall rating: 1 star (much below average)

Untreated bedsores are an all-too-common feature in this list -- and at the Grove of Berwyn Nursing Facility as well. Not one but at least four residents had major bedsores that were not properly taken care of. Due to not following basic regulations, some of these sores became stage three, meaning it's eaten all the way through the skin and now exposes the fat. 

Inadequate sanitation while cleaning wounds, improper settings on air bed due to lack of training, broken equipment, and not following basic policies and procedures all contribute to this facility’s terrible track record with bedsores.

Champaign Living Center -- Champaign

Medicare.gov overall rating: 1 star (much below average)

Anyone knows that older people can sometimes be hard to work with. They can get angry or frustrated because of their limited mobility or health issues. But that simply means nursing home staff have to be patient and supportive - not so with one incident at Champaign Living Center. 

A wheelchair-bound resident needed to use the toilet and required assistance. Two staff members tried to help him, but the resident apparently got frustrated and demanded to be taken back to his room.

Instead of calming him down and ensuring that he used the toilet, they simply took him back to his room and left him there alone with his spouse. He subsequently urinated on himself. Then his spouse tried to help him by giving him something to clean himself with. The resident stood up to do so and immediately fell, breaking his leg, for which he had to be hospitalized.

For this and many other deficiencies, Champaign Living Center makes our list.

Illinois Nursing Home Abuse Lawyers

No matter their age or mental ability, nursing home residents are human beings with all the rights that come with that. Bedsores, falls, medication mishaps -- all of these things are easily prevented with good policies, proper training, and staff who care about following the rules. Yet as we can see here, for many nursing facilities, these basic requirements are hard to follow, resulting in severe injuries and even death. If something like this happens to you or your loved one, call us. 

Our experienced team and national network of assisted living facility neglect lawyers are standing by and ready to help. For more information, contact us online, by email [hidden email] or by phone at 833.201.1555.

Do you work at a nursing home and know of abuse or neglect? You may be entitled to a cash reward. Visit our Medicare fraud nursing home whistleblower sister site for more information.

Aperion Care – the Worst Nursing Home Care in Illinois?

Almost every one of the facilities on our worst nine nursing homes in Illinois is operated by Aperion Care. The Illinois based company has 35 facilities, none of them where we would send a loved one.

In recent years, the company has been fined repeatedly. Many of the violations are shocking. Many of the companies nursing homes are rated by Medicare as “much below average. 

The Illinois Department of Public Health has fined the company hundreds of thousands of dollars over the last two years. Included in the fines were:

  • the strangulation death of another resident.
  • the death of a dementia patient found in a river after he fled an Aperion facility.
  • the death of a resident found in a pool of blood 
  • the death of a patient caused by an insulin spike after staff failed to monitor his blood sugar.

As noted above, Aperion Care operates many nursing homes in Illinois. We believe they are the worst nursing home operator in the Midwest. Here is a list of their facilities (highlighted facilities are discussed above): 

  1. Aperion Care Bloomington
  2. Aperion Care Bradley
  3. Aperion Care Bridgeport
  4. Aperion Care Burbank
  5. Aperion Care Cairo
  6. Aperion Care Capitol
  7. Aperion Care Chicago Heights
  8. Aperion Care Demotte
  9. Aperion Care Dolton
  10. Aperion Care Elgin
  11. Aperion Care Evanston
  12. Aperion Care Fairfield
  13. Aperion Care Forest Park
  14. Aperion Care Galesburg
  15. Aperion Care Galesburg North
  16. Aperion Care Highwood
  17. Aperion Care International
  18. Aperion Care Jacksonville
  19. Aperion Care Litchfield
  20. Aperion Care Marseilles
  21. Aperion Care Mascoutah
  22. Aperion Care Midlothian
  23. Aperion Care Moline
  24. Aperion Care Morton Villa
  25. Aperion Care Oak Lawn
  26. Aperion Care Olney
  27. Aperion Care Peoria Heights
  28. Aperion Care Plum Grove
  29. Aperion Care Princeton
  30. Aperion Care Spring Valley
  31. Aperion Care Springfield
  32. Aperion Care St. Elmo
  33. Aperion Care Toluca
  34. Aperion Care West Chicago
  35. Aperion Care Wilmington

As of this writing, the company is in negotiations to purchase Hope Creek Care Center, which is currently operated by Rock Island County. Area residents have objected to the sale, primarily because of fears of poor care.

To learn more about what you can do about nursing home abuse and neglect, contact us. Consultations are always free, without obligation and confidential. Please contact online, by email [hidden email] or call us at 833.201.1555 to set up a time to talk. We or someone in our network will look respond immediately. 

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Related topics: assisted living facilities (17) | code violations (5) | poor staffing (14) | substandard care (50)


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