Press Release

July 8, 2005



SPRINGFIELD, Ill. – The Illinois Department of Public Health today announced the following type “A” violations of the Nursing Home Care Act for the month of May 2005. An “A” violation, which is the most serious licensure violation levied by the state, creates a condition in which there is a substantial probability that death or serious mental of physical harm will result.

The statement of violation for each facility can be obtained by visiting the Department’s Web site at and clicking on the phrase “statement of violation” contained in the paragraph about the facility.

Alden Alma Nelson Manor, a 268-bed skilled care facility located at 550 S. Mulford Ave. in Rockford, has been fined $50,000 (Statement of Violation) for failure to educate and train nursing staff on correct administration of intravenous (IV) fluids and medications; to ensure that registered nurses verify physician’s orders; to ensure that a nurse prepares and administers IV medications correctly; and to ensure that the facility staff cares for and changes IV devices according to facility policy. These failures resulted in a resident receiving the wrong type of IV, which contributed to her experiencing respiratory distress and dying. The facility has requested a hearing. No hearing date has been scheduled.

Hickory Nursing Pavilion , a 74-bed skilled and intermediate care facility located at 9246 S. Roberts Road in Hickory Hills, has been fined $10,000 (Statement of Violation) for failure to supervise and protect a resident after the resident’s roommate told staff that a male resident had entered their room twice and tried to sexually assault the woman. The incident was not reported or investigated, the physician was not notified and no steps were taken to protect the resident. Staff also did not update the male resident’s care plan to indicate new approaches and interventions to address his escalating behaviors. The facility has requested a hearing. No hearing date has been set.

Regency Nursing Care Residence , a 99-bed skilled, intermediate and sheltered care facility located at 2120 W. Washington St. in Springfield, has been fined $10,000 (Statement of Violation) for failure to assure each resident receives all necessary precautions and/or supervision to ensure their safety; turn on all door alarms when residents are not under visual control; to make sure door alarms can be heard throughout the facility; and to ensure safety alarms are functional and/or kept on residents who have been assessed as elopement risks. One resident was able to leave the facility unnoticed because she was not wearing her safety alarm. Staff knew the resident had cut off 10 wrist devices and thrown them away, but did not revise her care plan or initiate new interventions. After the incident, the facility began placing the alarms through her shoelaces. The facility has requested a hearing. No hearing date has been scheduled.


idph online home
idph online home

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