In January, a resident staying at a nursing home in Urbana fell from her recliner while reaching for her glasses.
Several days later, she was left temporarily unattended near the bathroom while a nurse grabbed a mechanical stand lift. She fell by the toilet and had to yell for help because her call light was not with her, according to state inspectors.
This resident’s experience, however, resulted in a less severe Type B violation under Medicare guidelines. Violations are ranked on a scale from Type AA to C depending on how likely physical or mental harm is to occur. Type AA is the most severe violation and indicates the facility is liable for a resident’s death.
So far in 2024, the home, Clark-Lindsey Village, has a four out of five star rating on the federal Medicare site and is the only facility in Champaign County with its annual survey findings posted on the Illinois Department of Public Health (IDPH) website as of publication.
There are three other nursing homes listed in Champaign County. Standard inspections are conducted every six to 15 months. An additional inspection is done for every complaint that is filed.
None of the nursing homes mentioned returned repeated requests for comments.
All four homes received federal fines
The Medicare website shows all four nursing homes in Champaign County have been issued federal health citations since 2021. The four homes listed are Illini Heritage Rehab and Healthcare in Champaign, Clark-Lindsey in Urbana, Accolade Healthcare of Savoy and Country Health Care and Rehab in Gifford.
All facilities that receive funding from Medicare must meet both federal and state standards, which differ — but sometimes overlap — and are associated with different fines.
Clark-Lindsey was the only facility that was cited with the most severe violation, Type AA, in 2020.
The survey reported the facility did not complete a post-fall assessment after a resident had an unsupervised fall. After the resident was not eating and was lethargic, they were eventually hospitalized — but it was too late. The resident died from a brain bleed.
All facilities had violations in the freedom from abuse, neglect and exploitation category, but Accolade Healthcare of Savoy — formerly Champaign Urbana Nursing and Rehab until 2023 — was the only facility in the county cited for abuse on the CMS website. The violations for Accolade Healthcare of Savoy carry over from Champaign Urbana Nursing and Rehab.
The most recent Type A violation for abuse, neglect and exploitation at the facility, which is the second most severe violation, was in 2022 when Accolade was still under prior ownership.
The complaint was investigated on Aug. 26, 2022, and found a resident had lost 19 pounds in five days. The medical director at the time said “I should have been notified and was not. Losing excessive amounts of weight in such a short time frame could be very harmful to most residents.”
No nursing homes get five stars
Accolade Healthcare of Savoy had the most federal violations with 135, but Illini Heritage Rehab and Healthcare owed the most federal fines with $524,942. CMS gave both facilities an overall rating of one out of five stars.
The five-star rating system considers factors such as health inspections, staffing and quality measures.
Although Clark-Lindsey was the only nursing home in Champaign County that received four out of five stars, the facility has only 29 certified beds according to CMS — the least amount of beds available out of the four facilities. The next highest rating was Country Health Care and Rehab, which received two out of five stars.
Among the 10 violation categories, CMS records show the most common type of violation was in quality of life and care. The four facilities received a total of 107 violations in this category.
Statewide, quality of life and care violations were also the most common with over 9,500 violations. The reasons for these violations vary and include failing to provide appropriate medical care and not providing activities to meet the residents’ needs.
Data shows 677 Illinois nursing homes had health citations in the last three years, with fines totaling over $72.12 million.
Jennifer Guiney, a social worker in two different Illinois nursing homes for over 20 years who now works with domestic violence victims, said a common problem she saw was certified nursing assistants not following the care plan. She said certified nursing assistant (CNA) positions tend to have a lot of turnover, which leads to people not being properly trained.
“Overburdened, overworked; they’re trying to do their best, but they just have too many residents for one person,” Guiney said.
She said staff will often take shortcuts out of necessity and lack of time, and because they get accustomed to doing things a certain way, they also take these shortcuts when being watched by the state public health inspectors.
State fined Champaign County nursing homes $483,600
When state inspectors find deficiencies in care under federal standards, they issue a citation that may incur federal fines. But state governments may also impose additional penalties or fines, like Illinois does.
Each quarter of the year, the state public health department releases a report on all fines issued to nursing homes and care facilities throughout the state. These reports include information on the facility and its location, the standards violated, the fine amount and a link to the full inspection.
Since 2020, the reports showed $483,600 in state fines for the four homes in Champaign County.
Accolade Healthcare accounted for over half of the total fines with $272,000. Illini Heritage made up one-quarter, with $123,100.
Clark-Lindsey, however, was the only facility to receive more in state fines than federal fines. It received $81,900 in state fines, but only $1,644 in federal fines.
Guiney said the state public health surveys were always a crucial issue and that a nursing home would spend the whole year preparing for the visit. She said where she worked, the inspection was done in the same quarter every year, so they knew when to expect it.
However, if somebody filed a complaint, she said the state inspectors would walk in without warning to observe each department and interview staff, residents and family members.
IDPH Spokesman Michael Claffey said the inspection process is very strict and it is difficult to get information on violations beyond what is already in the inspection report. He did not respond on why certain violations are found more frequently than others.
Guiney worked in nursing homes until 2020, right around when the COVID-19 pandemic started. She said around the time she left, she thought the emphasis was placed on the wrong things — it became more paperwork-focused than resident-focused.
“I think what happens is, the nursing homes are making a spreadsheet for (the regulations set by the IDPH) to make sure they’re tracking it,” Guiney said. “Now you’ve got nurses and CNAs filling out tracking forms instead of maybe spending that extra time with the residents.”
Champaign County nursing homes are plagued with another problem: a deficit of beds. William “Avi” Rothner bought the former Champaign County Nursing Home and two other facilities in the county in 2018, but all have been closed since. As a result, Champaign County lost 463 beds.
While nursing home closures have been a common trend statewide, Guiney said non-profit nursing homes are especially hard to sustain economically. Our Lady of Angels in Joliet, where she used to work, closed in 2023.
Guiney said she only worked for non-profit nursing homes because for-profit homes “paid the people at the top so much money, and it doesn’t trickle down to the residents necessarily.”
When Guiney worked at Prairieview Lutheran Home in Danforth, a small town in Iroquois County, she said there was less turnover and a closer-knit community. Because nurses could be taking care of “their best friend’s family member,” Guiney said they took more pride in their work.
Clark-Lindsey and Country Health, which make up roughly 30% of beds in Champaign County, are both not-for-profits. Both of these facilities were rated higher by CMS than the for-profit homes and owed less money for violations.