Tuesday, December 30, 2008

Maplewood Care Fined for Failing to Supervise Resident

50 N. Jane in Elgin
FINED- August 19, 2003
Maplewood Care was fined $10,000 for failure to
provide adequate supervision to a resident who was
admitted to the facility for supervision. The
resident, who had a cigarette addiction, had offered
sexual favors to other residents in exchange for
cigarettes and was caught performing oral sex on a
resident. The woman also was physically aggressive
with other residents and often took cigarettes out of
their hands or slapped them on their arms while
demanding their cigarettes. These aggressive acts led
other residents to physically injure the woman.
Despite being aware of the resident's actions, the
facility failed to address these behaviors for several

Maplewood Care Cited for Failing to Secure Morphine


50 N. Jane in Elgin
FINED- 2002
Maplewood Care was fined $10,000 for failure to
safely store controlled substances, to maintain a
living environment free of hazards and to immediately
investigate a drug theft.
Responding to a complaint, Department surveyors
learned a female resident took morphine from a nurse's
cart and gave it to a male resident, who later died
from an overdose of the drug. Another resident had
observed the theft and reported it to a nurse, but she
did not investigate the incident or share the
information with a co-worker.
When the nurse realized 14 tablets of morphine were
missing from her cart, she called her supervisor, who
told her to write a note and slip it under her office
door and she would follow up on it in the morning. The
supervisor also told the nurse there was no need to
monitor the resident because she would not overdose.
Nearly seven hours later, the male resident given the
morphine was banging his head on a dresser and was
transported to the emergency room and admitted for a
drug overdose.
The resident had a history of substance abuse and was
admitted to the facility after attempting to overdose
on heroin. His pre-admission screening stated he was
in need of structure and supervision.
Following the incident, the female resident signed
herself out of the facility against medical advice.
She later confessed to stealing morphine and giving it
to the male resident so he could get high. She has
been charged with drug induced homicide, delivery of a
controlled substance and possession of a controlled
Surveyors found the female resident's care plan did
not address an arrest for shoplifting and her suicidal
statements and did not evaluate her medication seeking
The Department-ordered plan of correction required
the facility to review its policies regarding
administering medications and reporting of medication
errors; to ensure medications are locked in a
medication cabinet, room or cart; to take disciplinary
action against any staff failing to report, monitor or
take appropriate action in relation to medication
issues; and to have adequate staff to meet residents'

Wednesday, December 24, 2008

Dolton Healthcare Centre Failed to Prevent Resident from Wandering

14325 S. Blackstone Ave. in Dolton.
FINED- June 9, 2004
Dolton Healthcare Centre was fined$5,000 for failure
to prevent a resident from leaving the facility
Responding to a complaint, Department surveyors
learned a resident wandered from the facility wearing
only pants, a T-shirt and socks. The ground was
covered in snow and the temperature was in the single
digits at the time.
The facility did not know the resident had left until
a motorist notified staff that she had seen the woman
walking toward an Interstate exit ramp.
Prior to this incident, the resident had made numerous
attempts to leave the facility and was able to get
away four times despite wearing an electronic
monitoring device and being assigned one-to-one
supervision. Following these events, the facility did
not reassess the resident's care plan or strategies to
keep the resident from wandering.
A Department-ordered plan of correction required the
facility to adequately supervise residents, and to
train staff on how to assess residents for their risk
of wandering and the appropriate interventions to
prevent residents from leaving the facility

Countryside Healthcare Center Fined for Allowing Unsupervised Patinent to Drown

1635 E. 154th St. in Dolton
FINED- November 15, 2001
Countryside Healthcare Center was fined$30,000 for
failure to supervise a resident, to provide nursing
services in accordance with resident needs and to
properly assess a resident’s condition.
Responding to complaints, Department surveyors
learned that a resident, who could not sit upright
without assistance, was left alone for three minutes
while taking her bath. Upon returning to the bathroom,
staff told surveyors the resident was coughing, had
white secretions coming from her mouth and had trouble
breathing. She was transferred to the local emergency
department where she died.
A coroner’s report revealed the resident had water in
her stomach and lungs and listed her cause of death as
asphyxia due to drowning.
In a separate complaint, Department investigators
learned facility staff failed to ensure residents
received nursing care to prevent the development of
pressure sores and to ensure residents with pressure
sores received appropriate treatment to promote
healing and to prevent infection.
One resident developed 16 sores during a two-month
period and had to be hospitalized for treatment. A
review of nursing notes and hospital records revealed
insufficient documentation of the resident’s pressure
sores, a discrepancy in the resident’s weight and a
failure to implement a dietician’s nutritional
Surveyors also found the facility neglected to
properly assess the same resident’s condition after
she broke her hip. Facility medication administration
records indicated the resident, who was on a pain
management program, was given medication sporadically
and did not receive any medication on at least six
days, although she was reportedly in pain.
A Department-ordered plan of correction required
facility administration to ensure proper supervision
of its residents while bathing; to re-evaluate
pressure sore prevention and treatment programs; and
to review its policies addressing resident pain
assessment and pain management.

Thursday, December 11, 2008

Golfview Developmental Center Fined for Failing to Prevent Bed Sores

9555 W. Golf Road in Des Plaines
FINED- 2003
Golfview was fined $10,000 for not ensuring residents
received nursing services to prevent them from getting
pressure sores or facilitate healing of the sores. In
one instance, the facility failed to discover a
resident's pressure sore until it had reached an
advanced stage. The facility also did not have
complete and consistent documentation of another
resident's pressure sores that had not improved.

Ballard Nursing Center Fails to Maintain Door Alarm

9300 Ballard Road in Des Plaines
FINED- July 29, 2004
Ballard Nursing Center was fined $5,000 for failing
to supervise a resident who left the facility through
a back exit door that had a disabled alarm. The door
locked behind the resident and she was unable to get
back into the facility until an employee heard her
knocking. While outside, the resident sustained two
bumps on her head and a cut elbow. The facility was
unaware the door alarm was disabled.

Tuesday, December 9, 2008

Crestwood Terrace Nursing Home Cited for Failure to Monitor Hydration

13301 S. Central Ave. in Crestwood
FINED- 2003
Crestwood House was fined $5,000 for failing to
ensure that a resident receiving tube feedings was
getting the appropriate care to prevent dehydration
and metabolic abnormalities. The resident was admitted
to the facility with an order for sodium chloride,
which the facility continued to give to her even
though lab results showed elevated levels of the
compound. The facility failed to assess why the levels
were high and failed to take corrective measures.
The resident was eventually hospitalized with
respiratory failure. The hospital physician stated
that, while the elevated sodium level and resulting
dehydration did not cause the respiratory failure, it
contributed to the resident's medical condition.

Friday, December 5, 2008

Chicago Ridge Nursing Center Fined for Inadequate Supervision Resulting in Burn Injuries

Chicago Ridge
10602 Southwest Highway, Chicago Ridge
FINED- 2006
Chicago Ridge Nursing Center was fined $10,000 for
failure to adequately monitor and supervise residents
identified with unsafe smoking practices. As a result,
a resident suffered extensive burns to his face after
smoking while receiving oxygen therapy.

Prairie Manor Fails to Investigate Elder Abuse Claim

Chicago Heights
345 Dixie Highway in Chicago Heights
FINED- 2003
Prairie Manor Health Care Center was fined $5,000 for
failure to investigate an allegation of abuse and to
immediately take steps to protect its residents.
Department surveyors learned a resident signed herself
out of the facility against medical advice after
telling a supervisor that she was abused by three
staff members and was afraid to stay at the center.
The resident told surveyors that she reported
sustaining bruises after staff physically held her
The supervisor said she did not believe the bruises
were caused by staff so she did not initiate an
investigation nor did she report the allegation to her
The facility also failed to immediately remove the
employees suspected of abuse from resident care.
The Department-ordered plan of correction required
the facility to train its employees on reporting
incidents of suspected abuse and to protect residents
from harm.

Wednesday, December 3, 2008

Woodbridge Nursing Pavillion Fails to Monitor Suicidal Patient

2242 N. Kedzie in Chicago
FINED- February 22, 2002
Woodbridge Nursing Pavilion was fined $10,000 for
failure to provide appropriate nursing services and
supervision to a resident.
As part of an incident report investigation,
Department surveyors learned a mentally unstable
resident jumped from a fourth floor window and died
just 24 hours after he was admitted to the facility.
According to the resident's transfer records, he was
to receive constant supervision and medications for
his mental condition, but he did not receive any of
the prescribed drugs and was left alone.
Facility employees told surveyors they attempted to
contact the resident's physician to confirm his
medical orders, but the physician "did not respond" to
the calls.
Prior to the incident, the resident's behavior had
become increasingly agitated and he had threatened to
leave the facility. After the resident broke his
window with a dresser drawer, a staff member removed
the man from his room and left him unattended in the
hallway. Once alone, the resident ran into another
room and jumped out a window.
A Department-ordered plan of correction required the
facility to take all necessary precautions to ensure
the safety of its residents and to provide proper
supervision and personal care to meet the needs of its

Winston Manor Fined for Inadequate Supervision of Patient Who Suffered Burn Injury

2155 W. Pierce Ave. in Chicago
FINED- June 3, 2004
Winston Manor Convalescent and Nursing was fined
$10,000 for failure to take the necessary precautions
to ensure the safety of a resident and to investigate
Responding to a complaint, Department surveyors
learned a resident sustained second- and third-degree
burns to 26 percent of his body while smoking a
cigarette in the restroom. Staff told paramedics the
resident's cigarette somehow caught his shirt on fire.
The facility did not investigate the incident and
made no attempt to determine the cause of the injury
or to initiate measures to ensure that another
resident is not injured in the same manner.
A Department-ordered plan of correction required the
facility to review and revise, as necessary, its
policies on resident safety, smoking and supervision;
to provide adequate supervision; and to take all
necessary precautions to ensure the safety of
residents at all times.