January 15, 1998

SPRINGFIELD, IL —The Illinois Department of Public Health has given notice that it intends to revoke the nursing home license of Jacksonville Terrace and has fined the facility $10,000 for failure to properly supervise residents and prevent abuse. The 93-bed intermediate care facility is located at 1316 Tendick in Jacksonville.

Jacksonville Terrace has requested a hearing before an administrative law judge to contest the Department's action. As a result of its appeal, the Department's move to revoke the facility's license will be delayed until the hearing has been held. No hearing date has been set.

An investigation by the Department found numerous incidences of residents wandering from the facility, resident on resident assaults, medications not being given, verbal abuse by staff and staff not treating residents with respect and dignity.

In one instance, a 20-year-old male resident severely beat a 69-year-old female resident because she would not have sex with him. He then left the facility without staff's knowledge, stole a car and hit three bicyclists, killing one and injuring the other two.

Facility staff were aware of the man's history of explosive and violent behavior, but did not stop or question him as he led the woman into a shower room. The woman was found two hours later unconscious and naked on the shower room floor. She was hospitalized with multiple head injuries.

The resident responsible for the assault was to receive medications to control his behavioral problems, but over a five-month period the medicine was not given on 37 different occasions. Facility records revealed that the man had no violent outbursts in the month where he received all but one of his medications. However, in the other months, when medications were missed, he was involved in 19 inappropriate behaviors, many resulting in violence towards other residents.

Examples of other deficiencies found during the Department's investigation include:

• A 68-year-old male resident wandered from the facility 14 times in four months, including one time in which he was found in Springfield. The facility did not have a plan to address the resident's tendency to leave the facility.

• Six times in less than two months a 70-year-old resident wandered from the facility and was found in various places around the city, sometimes without appropriate clothing.

• Surveyors observed several instances when door alarms were shut off and facility employees were not nearby to make sure residents did not leave. Staff also said residents could turn off door alarms themselves to go outside to smoke, but without visual supervision.

• The facility policy is to initiate a search if a resident, who has permission to leave the facility with a pass, is one hour late from the agreed to time for returning. Surveyors, however, found two residents were gone for more than five hours before staff went to find them. In regards to one of the residents, staff told surveyors, "If it's still daylight we really don't worry about her."

• A staff member was verbally abusive of a resident for being incontinent.

• Surveyors observed staff who ignored requests by residents for food and drink, did not provide them privacy when conducting banking transactions, and did not assist them with clothing that was in disrepair or was not worn properly.

Illinois Department of Public Health 535 West Jefferson Street Springfield, Illinois 62761 Phone 217-782-4977 Fax 217-782-3987 TTY 800-547-0466 Questions or Comments