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 \u201csevere\u201d violations led to residents\u2019 deaths, the agency announced this week.\u00a0<\/p>\n
One of the heftiest fines, at $50,000, was given to Cicero\u2019s City View Multicare Center. IDPH found that the facility didn\u2019t properly supervise a cognitively impaired resident\u2019s eating, saying the 60-year-old man choked and died as a result.\u00a0<\/p>\n
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\u2019t included in the report.<\/p>\n
Staff told emergency responders on Oct. 12, 2024, that the man \u2014 who was on a pureed diet \u2014\u00a0 grabbed a turkey sandwich and began choking. Nurses said the resident clutched his throat and looked like he was \u201ctrying really hard to cough,\u201d 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 \u201chypoxic cardiopulmonary arrest,\u201d the report said.\u00a0<\/p>\n
A spokesperson for Cicero confirmed that the police department responded to MacNeal Hospital after being notified of the resident\u2019s death. The Cook County medical examiner\u2019s office ruled the death an accident.\u00a0<\/p>\n
Statewide, the agency handed out nearly 250 fines in the first quarter of 2025, including four \u201cAA\u201d 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\u2019s long-term-care facilities serve more than 100,000 residents.\u00a0<\/p>\n
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 \u201cbeing held to increasingly high standards.\u201d He said facilities often appeal the violations for factual inaccuracies.\u00a0<\/p>\n
Individual operators referred questions to the HCCI to comment on the state public health department\u2019s findings.\u00a0<\/p>\n
\u201cWe take all violations seriously and work closely with our members to make sure any issues are addressed quickly and thoroughly,\u201d Nunziato said. \u201cWe 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.\u201d<\/p>\n
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,\u00a0and failed to\u00a0properly intervene for low blood sugar, ultimately leading to a patient\u2019s death.<\/p>\n
The report stated that staff found that a resident \u2014 who had been seen \u201cfidgeting\u201d with medical equipment \u2014 had removed a tracheostomy tube early in the morning last October. The report said the resident didn\u2019t have a pulse due to lack of breathing support. The report didn\u2019t state the resident\u2019s age or gender, but said they had \u201csevere cognitive impairment\u201d and was unable to follow commands,<\/p>\n
When a respiratory therapist noticed that the resident didn\u2019t 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 \u201ccode blue\u201d over the overhead speaker. The therapist and a nurse from the next unit over performed CPR until paramedics arrived, the report said.\u00a0<\/p>\n
\u201cThe 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,\u201d the report said.\u00a0<\/p>\n
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\u2019t called quickly enough, the report said.<\/p>\n