Three Jacksonville long-term care facilities were cited by the Illinois Department of Public Health for violations of the Nursing Home Care Act in the fourth quarter of 2024. The list was released by IDPH on Thursday.
Arcadia Care of Jacksonville received a Type B violation for not following resident care policies. According to the report, on August 16, 2024 a resident was in their bed with a large cow bell and air horn at bedside to alert staff when they needed assistance to use the toilet. A nurse interviewed for the incident said that the call light system on the unit was not working and that ownership had ordered the part, but there was no timetable on when the issue would be fixed. Despite the alert method, the resident reported that they could not get staff to come assist them. The resident told IDPH representatives that they had to urinate in their own water pitcher in order to not do it on themselves, and had also recently been diagnosed with a urinary tract infection because they’ve been holding it too long due to the lack of help. Four other patients interviewed over the next four days also complained of similar neglect – some due to cases that the bell in their room was inaudible at the nurse’s station. The facility was fined $2,200.
The Grove Health & Rehab Center received two Type A violations and a Type B violation. According to their report, the facility was cited for failure of General Requirements for Nursing and Personal Care on two occasions. The report says the facility failed to ensure personal use items were within reach and provide an environment free of clutter to prevent falls and injury for 1 of 6 residents taken in a sample. As a result, a resident sustained a cervical fracture, requiring the wearing a neck brace for two months, as well as stitches to their head after falling to the bathroom floor attempting to use a urinal. The report also lists two large oxygen tanks that weren’t in use inside the resident’s quarters causing clutter. The resident had previously fallen on these tanks but with minor bruising due to the fall.
The second occasion cited the facility for failure to assess, monitor, and implement interventions to prevent weight loss in 1 out of 5 residents according to their care plan. Due to a particular patient’s diagnosis, the facility was documented as to not providing assistance to a resident during meals, as a result the resident lost approximately 11 pounds over a two-month period. Procedures of notification on the weight loss were said to have not been followed.
The third occasion noted that a medication regimen was not properly followed for a resident diagnosed with seizures. According to the report, the resident missed 28 doses of an anti-seizure medication resulting in the resident having 10 seizures, including hospitalization as a result. The facility was given a total fine of $52,500.
Jacksonville Skilled Nursing and Rehab received two Type B violations. According to the first report, the facility failed at General Requirements for Nursing and Personal Care. The facility failed in a sample of 1 out of 3 patients to provide general supervision for a resident who is prone to falls. The failure resulted in a resident falling and obtaining a laceration to the head, sutures, and experiencing pain. According to a nurse’s aid report, they were attempting to move the resident to the side of their bed with the bed elevated. The aide attempted to get the bed remote and was out of reach of the resident when they fell, possibly due to the resident reaching out for something.
According to the second report, failed to properly inflate an air mattress that resulted in a resident falling to the floor suffering a laceration on the right side of the head and several skin tears. The air mattress bolsters were used to keep the resident from rolling out of bed. The air mattresses were found to be defective and also may have been due to a bed setting too high. The facility was fined a total of $4,400.