November 9, 2001

SPRINGFIELD, IL. – The Illinois Department of Public Health has fined River Bluffs of Cahokia Nursing & Rehabilitation Center $10,000 (statement of violation) for improper screening of residents and for accepting residents who did not belong in a nursing home facility. Some of those admissions resulted in violence and inappropriate behavior toward staff and other residents, including a sexual assault. The 130-bed intermediate and skilled care facility is located at 354 Jerome Lane in Cahokia.

As part of an annual survey and incident and complaint investigations, surveyors learned a 44-year-old male resident sexually assaulted a 78-year-old female resident. A nurse heard the female resident scream and, when the staff member entered the room, she found the two partially undressed and in bed together.

The male resident, who is diagnosed with a mental illness, had a history of inappropriate and violent behavior. While at another facility, he attempted to kick a staff member in the head and struck a female resident in the face. River Bluffs is not allowed to admit people with mental illness who can reasonably be expected to inflict serious physical harm on him- or herself or on others.

In other instances, a resident with a history of inappropriate and violent behavior knocked an elderly woman from her wheelchair, another resident struck a fellow resident and another resident exhibited physically aggressive behavior toward staff.

Department investigators discovered River Bluffs often performed pre-screening tests after admission, and admitted residents who were determined not to be appropriate for nursing home care.

One resident was reported as not having a mental illness even though he had a diagnosis of schizophrenia. The resident had a history of making sexual remarks to women and touching them inappropriately.

Homeless residents and inmates on parole or probation from the Illinois Department of Corrections were admitted to the facility even though they had no need for nursing home care.

A staff member said she would visit shelters in St. Louis and East St. Louis to see if there were homeless people who could be admitted to the facility. Once at the facility, there were no special programs provided to enable the residents to return to the community.

There also were no special programs in place for the residents who had been admitted from the Illinois Department of Corrections, and staff were not advised about the former inmates’ convictions. Department of Public Health investigators, however, learned many were convicted of various degrees of sexual assault. Two of the former inmates were prohibited from having contact with young children due to their previous convictions, but staff were not aware of the stipulation.

Residents admitted from the state’s prison system did not receive additional supervision and were allowed to attend events inside and outside of the facility unsupervised.

A Department-ordered plan of correction required the facility to screen residents prior to admission to determine the level of care required and whether that care is within the scope of the facility, especially for mentally and developmentally disabled residents; to assess current

residents to ensure mentally ill and developmentally disabled residents in need of mental treatment or programming are not kept at the facility; to ensure residents are thoroughly assessed for history of and/or signs of inappropriate behaviors, sexually and physically abusive behaviors, and substance and alcohol abuse behaviors and that those behaviors are addressed and to properly supervise residents.

River Bluffs of Cahokia Nursing & Rehabilitation Center has requested a hearing on the Department’s actions. No hearing date has been set.