AU Well Care Home Failed To Both Protect Residents And Investigate Multiple Abuse Incidents Including Staff Biting Resident

The Illinois Department of Health has cited and fined AU Well Care Home when staff failed to properly protect residents from multiple incidents of abuse, including staff-to-resident abuse and numerous resident-to-resident altercations. The facility administrator failed to thoroughly investigate abuse allegations, properly document incidents, report them to authorities within required timeframes, or implement effective protection plans for vulnerable residents with mental health diagnoses.

This case documents a disturbing pattern of abuse, violence, and neglect at a nursing facility specializing in psychiatric care. The investigation uncovered eight separate abuse incidents, including physical altercations between residents and staff-to-resident abuse, all of which lacked proper documentation, investigation, and follow-up as required by regulations.

One of the most serious incidents involved a physical altercation between a resident with bipolar disorder and a certified nursing assistant (CNA). According to the resident, after complaining about how staff had picked her up after a fall, the CNA “scratched her face, hit her in the eye, and bit her finger.” When examined by the surveyor, the resident had multiple injuries: several scabbed scratches around her left eye (measuring 1-inch, 1-inch, 1/2-inch, and 1.5-inch), a 2 cm scabbed scratch on her nose, a 2 cm scabbed scratch on the tip of her nose, a 2-inch scabbed scratch below her right eye, and a bruised/swollen right eye with yellow drainage. Her right pinky finger had a 1/2 inch laceration.

Hospital records confirmed the resident had been involved in an “altercation with staff member” and documented that she had been “scraped on her left cheek” and sustained a “human bite of finger” that required antibiotic treatment. The hospital report cautioned that “human bites are often more serious than animal bites” and “wounds are more likely to become infected because of the germs in a person’s mouth.”

Witness accounts contradicted the administrator’s initial claim that the CNA was merely defending herself. A nurse who was first on the scene stated, “I was the first one on the scene. [The resident] was holding onto [the CNA’s] hair and [the CNA] was holding on with hand to her hair and the other hand she was pushing on [the resident]. [The resident] has scratches on her face that were open and bleeding. The scratches were on her whole face.” This nurse specifically noted, “I did not see [the resident] holding any pillowcase,” contradicting the administrator’s claim that the resident had been swinging a pillowcase filled with soda cans.

The situation worsened when a licensed practical nurse (LPN) later threatened the same resident. A Regional MDS Consultant provided a written statement describing how he heard the LPN tell the resident he “wasn’t going to ‘allow her’ to ‘attack’ another female staff member and if she did, he was going to ‘beat her to death.'” Despite this threat occurring in the administrator’s office, no immediate action was taken to protect the resident. The Regional MDS Consultant reported that when he tried to intervene, the administrator told him to “keep my mouth shut about thing I don’t ‘know what I’m talking about.'” The LPN was allowed to continue working that night and was later permitted to resign rather than be terminated.

The investigation also documented multiple resident-to-resident incidents, none of which were properly investigated or documented. These included a resident punching another resident in the face, causing visible bruising; a resident hitting another resident who was screaming; a resident grabbing another resident’s arm to prevent being punched; and verbal abuse between residents that was witnessed by the surveyor. In one case, two residents who had been involved in a physical altercation were observed sitting unsupervised just five feet apart from each other in the dining room after the incident.

When asked for documentation of investigations, the Regional MDS Consultant candidly admitted, “I am not going to lie we have nothing.” The Regional Chief Executive Officer confirmed the facility had no written investigations for any of the incidents. The administrator was described as a “no call no show” during part of the investigation, and staff could not locate any documentation of the reported incidents.

The situation was particularly concerning given the facility’s specialization in psychiatric care, with many residents having diagnoses such as bipolar disorder, schizophrenia, depression, and anxiety. Despite these complex needs, there was no evidence that staff had received specialized training on caring for residents with mental illness.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.