SPRINGFIELD, Ill. – The Illinois Department of Public Health has moved to revoke the operating license of Pine Lawn Manor and fined the facility $95,000 for substantial failure to comply with the Nursing Home Care Act. The 68-bed intermediate care facility for the developmentally disabled is located in Sumner, Ill.

The owners of Pine Lawn Manor have requested a hearing to contest the department's action and, as a result, the revocation action will be delayed until a hearing has been held. No hearing date has been scheduled.

The department gave notice it intends to revoke Pine Lawn Manor's license due to the facility's failure to implement an imposed plan of correction ordered last year to ensure staff are aware of the level of supervision required for each resident, to thoroughly investigate all allegations of physical or sexual assault and to protect residents from physically or sexually aggressive residents.

As part of an incident report investigation, department surveyors had learned the facility did not provide the necessary monitoring and supervision to a resident with a history of inappropriate sexual interactions with others (statement of violation). The resident was to be checked every 15 minutes after he engaged in a non-consensual sexual act with his roommate. Six days later the resident was involved in a non-consensual sexual act with his other roommate. The facility did not thoroughly investigate the incidents or remove the resident from the room he shared with the two men until a department surveyor entered the facility.

During a complaint investigation, the department also earned the facility neglected to take action to protect residents of the facility from resident-to-resident abuse or to prevent a reoccurrence of these incidents (statement of violation). In addition, it was found the facility did not provide sufficient, competent trained staff to protect at least nine residents who had been subjected to psychological and or physical abuse from newly admitted clients to the facility.

A three-month review of facility records found 25 documented incidents of resident-to-resident aggression, with 24 of these incidents involving newly-admitted clients to the facility.

It was also noted the facility failed to provide the necessary monitoring and supervision for residents with self-injurious or disruptive behaviors. One resident would stick objects in his ear and smoke unsupervised. Another resident pulled sinks from the bathroom walls, twice resulting in injuries to himself.

The facility admitted clients who had mental illness, but did not provide staff trained to deal with mental health needs or physically aggressive clients.

In July , the facility was fined $15,000 for failing to have enough trained staff to provide adequate resident supervision and to conduct a thorough investigation of a possible sexual assault involving two residents. Following the incident, the facility was ordered to ensure that enough staff is available to care for residents and to thoroughly investigate all allegations of assault.

In February , Pine Lawn Manor was cited for three medication errors in a six-week period, failure to follow proper procedure for checking placement of feeding tubes prior to administering medication and not properly disposing of expelled or refused medications (Statement of Violation).

An April complaint investigation resulted in the facility being cited for not ensuring a resident with a history of constipation was properly monitored. The resident had to be transferred to a hospital where he died (statement of violation).

Source: Illinois Department of Public Health