Are Illinois Residential Care Facilities Adequately Regulated? Exploring Oversight Amid Abuse and Neglect Incidents

Nursing home regulations aim to guarantee that residential facilities provide safe, sanitary, home-like environments where residents receive quality care. Inadequate regulation in nursing homes has resulted in an epidemic of nursing home abuse and neglect. We are passionate advocates for reform who fight for change and hold nursing homes accountable when they harm residents by failing to provide the care and respect they deserve.

Nursing home abuse and neglect is an ongoing nationwide crisis that has persisted for decades amid lax nursing home regulations. Many nursing home providers are powerful corporations that use their wealth to influence public policy so they can continue to underfund nursing homes, which perpetuates the cycle of nursing home abuse.

As many as 15 percent of adults living in United States nursing homes report experiencing some form of abuse, including physical abuse, psychological abuse, sexual abuse, financial exploitation, and neglect. The actual numbers may be significantly higher, as the majority of cases are unreported.

Illinois nursing homes have long been among the nation’s worst offenders, as evidenced by the following:

• In 2017, Illinois had the highest incidence of sexual abuse in nursing homes.
• In 2018, Illinois was the worst state in the nation for overusing psychotropic drugs in nursing homes.
• In 2019, Illinois ranked last in the nation for nursing home staffing, a driving factor in nursing home abuse.

State and federal regulators are not doing enough to protect our vulnerable elderly population in nursing homes, which are the very places where they should feel the safest. In recent years, we have handled cases against Illinois nursing homes for egregious conduct that authorities did not appropriately address, including the following:

• Videotaped Bullying Incident: Two CNAs in a Chicago nursing home bullied a 91-year-old resident with dementia, videotaped it, and posted it on social media with laughing emojis. The nursing home failed to investigate or report it to the Illinois Department of Health until the family involved the police. The two CNAs were arrested on misdemeanor charges, and the nursing home terminated their employment. There is no record that the facility faced discipline for the incident.
• Neglect and Retaliation: A 96-year-old World War II veteran developed pneumonia after the Westminster nursing home in Evanston failed to properly address a burst sewage pipe over his room. He was then left unattended, causing him to fall, break his pelvis, and eventually develop bedsores. After he filed his complaint, the facility filed an eviction action in apparent retaliation. Westminster was rated a five-star facility. The family is suing under the Illinois Nursing Home Care Act. There is no record that the facility was ever cited or fined over this incident.
• Death Caused by Lack of Attendance: A Chicago nursing home’s staff allowed a man to bleed to death from his arm by failing to regularly check on him after a successful kidney transplant. He was a known bleeding risk. An employee with a criminal record also stole his phone around the time of his death. His death was not discovered until three hours after he died. The Illinois Department of Health only cited the facility for failing to properly report the death.

These are not isolated incidents. Scenarios like these play out daily in nursing homes nationwide with little or no consequences to the nursing home companies.

A scathing investigative report in Maine found that the state health department failed to take action in 91 percent of the 348 abuse and neglect reports regarding assisted living facilities throughout the state from 2020 to 2022.

Thirteen facilities in Maine had 10 or more neglect and abuse incidents. One facility received seven visits from public health officials during this period. Such incidents as the following are known to have occurred at this facility:

• A resident with dementia was given a peanut butter sandwich despite a documented peanut allergy, resulting in death from anaphylactic shock.
• An employee slapped a combative resident in the face.
• A resident wandered outside into the snow without the facility noticing for two hours. The resident died of complications from hypothermia.

The facility was not fined for any of these incidents but was only required to develop a plan of correction. With no real consequences, there is no incentive for change.