SPRINGFIELD, IL – The Illinois Department of Public Health has given notice that it intends to revoke the license of The Abbey of Carbondale - Little Willow for substantial failure to provide quality care and has fined the facility $30,000 (Statement of Violation) in the past 10 months. The 239-bed skilled care facility and skilled care facility for persons under the age of 22 is located at 120 N. Tower Road, Carbondale.

The owners of The Abbey of Carbondale - Little Willow have requested a hearing to contest the Department's action. As a result, the Department's move to revoke the facility's license will be delayed until a hearing has been held. A hearing date has not been scheduled.

The Department's action is the result of a series of problems at Little Willow in the skilled care facility for persons under the age of 22 section of the complex that began earlier this year when the facility was disciplined for neglecting to ensure a resident was provided the necessary supervision to avoid physical harm. In January, Department surveyors found the facility did not complete a comprehensive pre-admission assessment of a child who suffered from a disorder that, in its later stages, caused the child to fall frequently. Less than 48 hours after being admitted to Little Willow, the boy had fallen twice, hitting his head both times. The first fall resulted in a head laceration that required five stitches and the second blow to his head resulted in his death.

In July, a Department investigation into additional allegations determined the facility failed to thoroughly investigate an attack by a resident that included him removing another resident's feeding tube and the physical and sexual assault of four other residents. Neither the residents' families, guardians or physicians or the Department were notified immediately.

Surveyors learned that a resident, who has a history of inappropriate sexual behaviors, exited his room unnoticed. He was found by staff partially clothed and attempting to sexually assault a male resident. After directing the resident back to his room, staff members also discovered a female resident stripped naked, with scratches on her face and toothpaste smeared on her body; the woman's roommate partially clothed with toothpaste smeared on her; a male resident whose diaper had been removed and shredded; and a male resident bleeding from the stomach where a feeding tube had been pulled out.

The facility only reported that a resident was found in a peer's bedroom, both fully clothed, and two female residents had toothpaste squirted on them – one of whom had a light abrasion – and no other injuries. When interviewed by Department surveyors, a staff member said the facility director told her not to document that a resident's feeding tube was pulled out or to indicate there was evidence of sexual activity with the females who were attacked.

Surveyors determined the resident who committed the abuse was able to exit from his room through a bathroom shared with the two female residents. The bathroom's door alarm was not functioning. Staff were to conduct nightly bed checks every15 minutes and to monitor hall cameras, but the residents had not been checked for 30 minutes because all but one staff member were on a break outside the facility.

Responding to another incident report and complaints, surveyors discovered the facility failed to properly monitor a 15-month-old resident whose tracheostomy tube often became dislodged.

On the night of his death, a nurse went to feed the child and found he was not moving. When she turned the boy over, the nurse noted his tracheostomy tube had come out and there was no heartbeat. She and another employee started cardiopulmonary resuscitation, but the child died at a local hospital.