An elderly man with Alzheimer's disease leaves a local nursing home without staff noticing and is found wandering into traffic on Mattis Avenue in Champaign.
A patient in an Urbana nursing home is left unattended on a bed pan for hours until the bed pan creates a deep pressure sore in its shape.
In another home, a patient who should be fed only soft foods is given orange slices that ultimately cause his choking death a few hours later.
These are just a few of the numerous examples of deficient care reported in area-wide nursing homes. Indeed, many nursing homes across Central Illinois have been cited repeatedly over the past five years for safety violations that put residents at risk for untreated pressure sores, bladder infections, serious medication errors and broken bones.
In some severe cases, residents have been rushed to hospitals or even died from lack of proper care.
Inadequate staffing issues and delayed public health insurance payments are major concerns among nursing home care facilities, but they shouldn’t be an excuse for poor care, said Tami Wacker, operations manager and regional ombudsman for the East Central Illinois Area Agency on Aging.
“When someone says, ‘I accept you, I will admit you, I can take care of you,’ they have made a promise and you need to fulfill that,” she said.
A close review by CU-CitizenAccess.org of hundreds of federal and state inspection reports on 93 Central Illinois nursing homes revealed:
- Fifty percent of nursing home beds that are Medicare or Medicaid certified are located in facilities rated below average by the federal regulatory site Medicare.gov;
- In Champaign County, four out of the seven nursing homes – which have 75 percent of nursing home beds that are available to Medicare or Medicaid recipients - are rated below average;
- Central Illinois nursing homes have paid more than $1 million in fines and penalties for violations from 2006 to 2010;
- State inspectors have found that low staffing levels and inadequate training have contributed to resident injuries and deaths at some nursing homes in Central Illinois.
Nursing home administrators across Central Illinois and health care advocates alike acknowledge that rating systems, such as those from the Centers for Medicare & Medicaid Services on Medicare.gov, do have problems. And nursing home owners say that late Medicaid reimbursements from the state are increasing their woes. [News-Gazette: Deadbeat Illinois.]
“But it does give a very good base,” Wacker said.
Wacker’s office acts as an advocate for nursing home residents across counties in Central Illinois. A private, nonprofit group, it handles about 600 complaints each year from across nearly 200 long-term care homes, and it reports problems to the state when serious health care issues arise.
On the regulatory front, long-term care facilities are certified through the federal agency for receiving Medicaid and Medicare reimbursements, but they are licensed through the Illinois Department of Public Health.
The health department does inspections for the federal agency during its own mandatory yearly survey. If complaints are made at a long-term care facility, the department is required by federal regulations to investigate the complaint.
The federal Centers for Medicare & Medicaid Services use a five-star system to rate the quality of homes that provide skilled nursing care and are certified to accept government aid payments. Each home is rated in three areas: health inspections, staffing and “quality measures.”
State officials, including registered nurses, conduct unannounced inspections of each certified facility about once a year, monitoring the care given to residents, staff-resident interactions and the overall environment of the home.
Nursing homes in Illinois report the hours their nurses and certified nursing assistants work to the state Department of Public Health. The federal agency uses this information to calculate each home’s average daily staffing hours per resident.
“Quality measures” are data on residents’ physical and mental health and well-being that nursing homes collect and report to the federal government. These include information such as the percentage residents with moderate to severe pain, the percentage of patients with bed sores and the percentage of residents whose mobility has declined.
After rating each of the three areas, the federal government uses those measures to give each home an rating for overall quality on the five-star scale, ranging from five stars for homes that are “much above average” to one star for homes that are “much below average.”
To review federal nursing home ratings, visit:
To review state information on nursing homes, visit:
If facilities are funded by Medicare and Medicaid and do not meet their requirements during an inspection, then they can be decertified and lose their funding.
For example, Helia Healthcare of Urbana closed in 2009 after regulators pulled its certificate for reimbursements because of poor patient care.
By law, facilities have to report any problems with patient care to the Illinois Department of Public Health, and then the department investigates. The state looks for a pattern; if the same type of serious violation continues to occur, then processes to revoke the facility’s license can begin.
“Each home is very different. What you see in one facility may not correlate to another, direct comparisons are not possible; it’s like comparing apples to oranges,” said Melaney Arnold, spokeswoman for the state public health department.
“Having them come in and write that deficiency will show that facility, you’ve got to change your way because this level of care is not acceptable,” Wacker said. “And if it’s not acceptable for this resident, it’s not acceptable for anybody else, currently or in the future, and we want to get that changed immediately.”
Nursing homes criticize rating system
Greg Wilson, vice president of quality management for Petersen Health Care, sharply critizes the ratings.
Petersen Health Care operates dozens of for-profit facilities across the state, and nine of its homes in Central Illinois are rated below average, according to the federal rating system Medicare.gov.
Wilson wrote in an email, “The system is based on a very subjective state survey process that is inconsistently applied across the country, faulty staffing statistics, and quality measures that are affected by too many factors to be descriptive of any resident’s actual clinical condition or needs.”
He wrote the system “makes no accommodation for the wide disparity between Medicaid reimbursement rates paid throughout the country of which Illinois is historically ranked at the very bottom. The rating has very little or no bearing on the quality of care being provided at any nursing home in the country.”
President and CEO Deb Reardanz of the nursing home Clark-Lindsey Village in Urbana said that while the rating system is good for consumers, “it doesn’t always capture the full picture.”
Clark-Lindsay is rated at average with its current rating of three out of five stars.
“I do not believe that tells the full story,” she said. “We are above average and we work hard to be a leader in the field, not just in the area, but throughout the state.”
She said the home received too low a rating.
“We’re not satisfied with the (rating),” she said.
Inspections and fines
Whether the ratings are warranted, the deficiencies reported can be shocking.
In one incident in May 2009, a crying and disoriented a man stumbled into the busy lanes of South Mattis Avenue in Champaign during rush hour traffic. Police reports say a passerby called to report the man in the street. The man, a patient at Helia Healthcare of Champaign, had left the nursing home and into the four-lane road without anyone noticing.
According to state quarterly reports, the passerby stated, “What scared me so bad was that no one from the nursing home knew he was there!”
The man, who had been admitted to Helia Healthcare of Champaign the month before, suffered from Alzheimer’s disease. Reports said he wandered out of a door left open with its alarm off while the nursing home was doing maintenance.
But it wasn’t the last time a resident had left the facility without the staff’s knowledge.
In January 2010, a 53-year-old man with Parkinson’s disease and a history of mental disorders was able to leave the facility without anyone noticing. He had been admitted to the nursing home after he “had fallen at home and was found living in unsanitary conditions.”
He later told inspectors that he walked out the front door to get a cup of coffee at a local restaurant and rode the bus before he was found later walking along Mattis Avenue, according to a state report. By his estimate, he was gone from the facility for about three hours before staff noticed.
Araceli Henson, administrator, at the Helia Healthcare in Champaign canceled two scheduled interviews for comment.
In summer of 2009, Champaign Urbana Regional Rehab Center, formerly known as Carle Arbours, was fined $10,000 after a patient choked on mandarin orange slices, ultimately causing his death the next day.
The resident was required to have a pureed diet, and was found with no pulse and solid food protruding from his mouth by a certified nursing assistant, according to a report. It took 24 minutes from the time the staff found the man unresponsive till the time someone called 911.
The home’s director of nursing later told investigators that orientation for new employees did not include training for the Heimlich maneuver, CPR, how to respond to resident emergencies or how to use the telephone system in an emergency, according to the report.
One certified nursing assistant told inspectors: “It was a lot of back and forth running around. Afterwards one of the other CNAs asked me why I didn’t use the phone in the dining room to call for help or page someone. I didn’t even know to use them for emergencies. I should have been told to do that in orientation but they never told me that. It would have saved a lot of time.”
An emergency room doctor who treated the man told the inspectors: “I would expect anyone in a medical situation to be informed of the basic life support systems and know how to rapidly access … (emergency medical systems).”
Administrators at the home did not respond to numerous attempts to reach them for comment.
Champaign County Nursing Home
In another incident in March of this year, a Champaign County Nursing Home resident was left on a bedpan for six hours, which resulted in a pressure sore. The sore – shaped like a bedpan – became infected and turned into a blood infection that required hospitalization and medication.
An employee told investigators, “I looked at her backside and it was split open. When I saw it I said, 'Oh my God' because I saw pink meat. I went and got the nurse.”
The nursing home was fined $25,000 in April for the incident.
Champaign County Nursing Home paid nearly $80,000 for violations from 2006 to 2010.
In October, Chuck Schuette took over as its administrator and inherited all of its problems.
“I do know that it’s really difficult trying to be in compliance with all of these issues,” he said. “I’m not saying they don’t need to be there, but you have to have a really dedicated work force, a highly-trained workforce, and they just have to stay on top of it all the time. “
He added, “And sometimes things happen, and you hate it when it does, and you have to correct it.”
The county nursing home also has been under intense financial pressure because of late Medicaid payments from the state.
But for Schuette, like others, money isn’t the main concern.
“If the resident isn’t number one in your facility, then how can you expect it to be successful?” said Chris Kasper, administrator of Country Health Care & Rehab in Gifford. “This is their home, and this is who we care for. Regardless of public health ratings and all the inspections, all that aside, it really just comes down to the morals and ethics, you know, what can you do? It’s not always about your bottom line.”
Former University of Illinois journalism student Sabrina Santucci contributed to this story.