Chicago-area nursing homes fined for ‘severe' violations that led to patient deaths, Illinois health department says

Chicago Tribune

17-07-2025

The Illinois Department of Public Health has doled out tens of thousands of dollars in fines to dozens of nursing homes throughout the Chicago area, including a handful where 'severe' violations led to residents' deaths, the agency announced this week.
One of the heftiest fines, at $50,000, was given to Cicero's City View Multicare Center. IDPH found that the facility didn't properly supervise a cognitively impaired resident's eating, saying the 60-year-old man choked and died as a result.
The resident was admitted to the facility in August 2023 with terminal illness under hospice services, the report stated. The man had diagnoses of dementia, diabetes and bipolar schizophrenia, and required supervision when eating. His name isn't included in the report.
Staff told emergency responders on Oct. 12, 2024, that the man — who was on a pureed diet — grabbed a turkey sandwich and began choking. Nurses said the resident clutched his throat and looked like he was 'trying really hard to cough,' the report said. When the nurse opened his mouth it was full of saliva. Although staff and paramedics attempted the Heimlich maneuver, the man died that night around 7:48 p.m. at the hospital of 'hypoxic cardiopulmonary arrest,' the report said.
A spokesperson for Cicero confirmed that the police department responded to MacNeal Hospital after being notified of the resident's death. The Cook County medical examiner's office ruled the death an accident.
Statewide, the agency handed out nearly 250 fines in the first quarter of 2025, including four 'AA' violations of the Nursing Home Care Act. Most of the incidents included in the quarterly report took place in late 2024 and early this year. The state's long-term-care facilities serve more than 100,000 residents.
Ron Nunziato is the senior director of policy and regulatory affairs for the industry trade group Health Care Council of Illinois, which represents nursing homes in the state. He said the state survey process is meant to highlight areas for improvement among facilities, which are 'being held to increasingly high standards.' He said facilities often appeal the violations for factual inaccuracies.
Individual operators referred questions to the HCCI to comment on the state public health department's findings.
'We take all violations seriously and work closely with our members to make sure any issues are addressed quickly and thoroughly,' Nunziato said. 'We remain committed to advocating for a strong and well-supported long-term-care system in Illinois, one that prioritizes resident safety, quality of life and workforce stability.'
Bria of Palos Hills in the southwest suburbs also received $52,000 in fines for two violations. For the most serious, IDPH found that the facility failed to prevent unintended removals of ventilators and tracheostomy tubes, which help patients breathe, and failed to properly intervene for low blood sugar, ultimately leading to a patient's death.
The report stated that staff found that a resident — who had been seen 'fidgeting' with medical equipment — had removed a tracheostomy tube early in the morning last October. The report said the resident didn't have a pulse due to lack of breathing support. The report didn't state the resident's age or gender, but said they had 'severe cognitive impairment' and was unable to follow commands,
When a respiratory therapist noticed that the resident didn't have a pulse, both nurses were on break and not in the unit, the report said. The therapist said it took about two minutes to leave the room and call 'code blue' over the overhead speaker. The therapist and a nurse from the next unit over performed CPR until paramedics arrived, the report said.
'The nurse assigned to (the resident) was outside the facility on break and did not return until after paramedics transferred (the resident) out of the facility,' the report said.
The resident was resuscitated by paramedics and admitted to the intensive care unit, the report said. However, about three weeks later when the resident was back at the facility, the fire department found the resident dead in their bed. Nurses reported that the resident was found to have low blood sugar earlier during rounds, and that 911 wasn't called quickly enough, the report said.
Sam Brooks, the director of public policy at the advocacy group National Consumer Voice for Quality Long-Term Care, called the report troubling but not particularly surprising, citing low staffing nationwide as the main issue. U.S. News & World Report recently ranked Illinois 47th out of 50 states for nursing home quality, based on federal reports of health inspections, staffing and other quality measures.
'Inadequate staffing results in corners being cut, care not being provided, folks falling or developing pressure ulcers or not getting their medication, and that's often and the most likely underlying cause,' Brooks said. 'I really can't understate the impact staffing has.'
In Brooks' experience, nursing home operators often view fines as the 'cost of doing business.' It's more costly to properly staff a facility than to pay a fine. Illinois nursing homes that consistently perform poorly can be placed in a Special Focus Facility program designed to improve care, an IDPH spokesperson said. Facilities in the federal program are subject to more inspections, escalating penalties and potential termination from Medicare and Medicaid.
'Every day, residents are dying and languishing from poor care and neglect and inadequate staffing, and it affects families,' he said. 'It devastates families and devastates residents. Until we focus on providing better care, we're just not going to get there.'