(Video produced by Nicole Cardos)
When nursing home resident Curtis Spears fell while getting out of bed, his sister Julia Preston and Belhaven Nursing Home and Rehabilitation Center staff members agreed on one detail: He fell.
How he ended up on the ground is where their stories differ.
Preston recounts Belhaven telling her that as Spears was being transferred to the bathroom, he lost his footing and fell.
Yet according to Preston, Spears had lost trunk control after a stroke years prior, and wouldn’t have been able to walk from his bed.
“He could recount the story almost verbatim,” Preston recalled. “[Staff] was helping him out of bed to his chair, the chair moved and he fell to the floor, hurting his left knee and ankle. Why did the aide not use [the mechanical lift]?”
Preston said the home never acknowledged the discrepancy in reports.
Her brother, who has since died, spent several years in the home located in Chicago’s Morgan Park neighborhood. The fall is just one of a series of issues Preston alleges in the numerous complaints to the home and the Illinois Department of Public Health (IDPH) she’s raised over the years.
Preston said the treatment at Belhaven is a symptom of a larger issue: a lack of standard enforcement by IDPH that leads to a racial and economic disparity in access to high-quality nursing homes.
“You can’t really blame Belhaven, because Belhaven is eating up the chicken and Public Health is letting them eat it,” Preston said.
An analysis by WTTW News and the Hyde Park Herald/South Side Weekly found that the disparity between access to quality nursing home care for Black and White Chicagoans is stark: Three of the city’s five-star homes, as rated by Medicare, house majority White residents and are concentrated on the city’s North Side. There is another five-star home on the North Side that did not submit demographic data for 2021 to the Illinois Health Facilities & Services Review Board (HFSRB), the agency that collects this information.
There is a five-star home on the South Side that houses majority White residents.
There is also a five-star home on the West Side, but the home also did not submit demographic data to HFSRB.
Among four- and five-star nursing homes, an average of 22% of residents are Black, while 70% are White.
Chicago’s population is 28.8% Black and 42.4% White, according to census data.
Medicare, the federal agency that evaluates nursing homes, rates a home’s performance using one through five stars on the basis of health inspections, staffing and other quality measures. One star means quality much below average and five means much above average quality.
Of the 16 nursing homes with majority Black residents in Chicago, 15 are one- or two-star homes.
Eight homes in Chicago did not submit their demographic data to HFSRB, including three North, three South and two West Side homes.
“Nursing homes that provide services for Black and Brown people, predominantly, those services are poor in the first place,” Preston said. “There’s serious racial disparities, when it comes to those persons who depend upon Medicaid to pay for their care.”
This disparity is also found in how residents are paying for homes: In those one-star homes, 91.6% of residents are using public sources like Medicare or Medicaid.
In 2010, the Illinois legislature passed updates to landmark nursing home reform legislation intended to address these disparities. That ambitious legislation included new requirements like minimum staff-to-patients ratios in homes and increases in the number of nursing home inspectors.
But 13 years later, a WTTW News and Hyde Park Herald/South Side Weekly analysis has found that IDPH has lagged in implementation of the legislation.
“It’s my life’s work down the toilet. I mean, like, 30 years of doing this, and the differences are so minimal,” said Wendy Meltzer, the former executive director of the advocacy group Illinois Citizens for Better Care.
“These really significant, theoretically, legislative victories — what happens afterwards is that nobody enforces them,” Meltzer said.
When asked about the disparities among area nursing homes and current efforts being taken to address them, IDPH officials pointed to recent legislation signed by Gov. J.B. Pritzker in 2022 that ties funding to staffing.
The lack of enforcement around staffing and inspections from IDPH is in large part why these stark differences in quality of care persist, according to multiple people interviewed for this story.
What’s also causing a lag in accountability of bad actors in homes is that nursing homes in Illinois aren’t required to carry liability insurance.
Attorney Steve Levin of Levin and Perconti said a substantial number of nursing homes are operating with grossly insufficient insurance to none at all — leaving ownership to dodge financial responsibility in lawsuits.
Two Homes: A Block Away, A World of Difference
For a deeper look into these disparities, take a look at Belhaven and Smith Village in Morgan Park on the city’s Southwest Side. Belhaven, a one-star home in which the majority of residents are Black, is a mere block away from Smith Village, a three-star home in which the majority of residents are White.
When comparing four years of reports from the Illinois Department of Public Health and Centers for Medicare and Medicaid Services (CMS), the difference in quality of care is stark.
In one reported incident at Belhaven, the facility failed to perform CPR on a resident, according to IDPH surveys. That patient died shortly thereafter.
In March 2021, a certified nursing assistant (CNA) found the 71-year-old resident “not responsive and slumped over in the bed,” with a faint pulse, and the CNA “didn’t really see [the resident’s] chest move.”
Yet the nursing assistant did not perform life-sustaining CPR because she mistook the resident for a DNR, otherwise known as a “do not resuscitate.” She “thought that [the resident] was a DNR because of his decline that he wasn’t well for a while,” the survey reads.
It was when family and other staff were notified of the resident’s death that the CNA realized the resident required full code care (i.e. all resuscitation measures), stating “O.M.G. [the resident] was full code,” according to the survey.
The survey also details that another nurse failed to provide visitation to immediate family members of a resident under the same name after the resident’s death.
In response to the incident, the home stated in a subsequent plan of correction that all residents in the facility have been assessed for either a Full Code or Do Not Resuscitate order.
Alleged issues about the quality of care at Belhaven go beyond this incident. In reports from 2019 to 2023 collected by IDPH, Belhaven has been cited for repeated cases involving a lack of fall prevention, failure to prevent abuse and COVID-19 mitigation.
Medicare has rated the home’s performance one out of five stars on the basis of health inspections, staffing and quality measures. According to the agency, Belhaven ranks “much below” the national average.
Over the past four years alone, the home has amassed a total of $118,700 in state fines and more than $879,000 in federal fines.
In 2021, Belhaven received nearly $13 million from Medicare and Medicaid from patients. It housed 170 residents.
The for-profit home has three owners with 5% or greater interest in licensee: Michael Blisko with 35% ownership, Moishe Guin with 16.2% and Tira Gubin with 16.2%. They all own about a dozen other homes with much overlap. Of the 13 other homes Blisko has ownership in, five have been cited for abuse and 12 of those homes have a one- or two-star Medicare rating.
One home under Blisko’s ownership is not rated due to a history of serious quality issues, according to CMS. The home, City View Multicare Center in west suburban Cicero, “is subject to more frequent inspections, escalating penalties, and potential termination from Medicare and Medicaid as part of the Special Focus Facility (SFF) program.”
Blisko did not respond to multiple requests for comment. The administrator for Belhaven said the facility had no comment.
IDPH wasn’t able to comment specifically on Blisko’s record, and said that home violations are not currently kept based on facility ownership.
The department did point out that they are currently in the process of implementing a new licensure system, which would “provide us additional insight into facility ownership.” They said they plan to roll out the system in 2024 and that it would give the department “additional capabilities to link multi-ownership to facility performance.”
Care Complaints and Staff Shortages
Staff at Belhaven, too, report difficulties within the home.
Walking into the home is overwhelming, according to a staff member. WTTW News is not using the staff member’s name due to fear of retaliation. They said it can smell like urine, that nursing stations are falling apart and, overall, residents aren’t getting proper care.
“They barely have nurses in here because don’t nobody want to be here,” the staff member said. “They barely have CNAs here to take care of the patients because of the lack of pay … so a lot of patients aren’t getting the proper care.”
One contributing factor to these conditions is chronic understaffing on the floor, the worker alleged. Meanwhile, multiple staffers’ hours are getting cut short, the worker alleged.
Typically, this staffer would work 75 hours per pay period, plus overtime. The staffer claims that lately, they’ve been reduced to 45 hours per pay period.
“How do they expect for us to live like that,” the staffer said. “We can’t pay our bills. … They act like they do not care.”
According to IDPH surveys, residents haven’t received proper incontinence care. According to a report dated June 24, 2022, a CNA and surveyor walked into a resident’s room where “the ammonia smell from the urine was so bad [their] eyes were burning” and the CNA said the soiled disposable brief from a resident weighed “about 7 pounds.” The resident stated that “no one changes her during the night.”
In another incident from a June 13, 2019, survey, the facility was cited for a failure to ensure incontinence care was provided in a timely manner. The survey details that a large amount of feces was noted on a fitted sheet and the resident was “heard crying out ‘please someone help me, please God, help me, help me.’”
Mya James, a CNA at the home, said she has seen these instances of neglect firsthand.
She’s worked in the home for about a year, primarily with patients who have dementia. She said a resident’s call light button was repeatedly put out of reach by another nurse — an action that James called abuse.
But when James brought this to the attention of her supervisors, she said, initial talk of investigating the matter soon faded. She said she was never interviewed by management, and IDPH inspectors never came to investigate the abuse complaint.
James said she was met with apprehension from co-workers about reporting this. She said there were rumors floating around and people were “talking bad” about her.
“You mean to tell me you guys care more about (employing) workers than the abuse and the care of patients in the facility?” James said.
Though she said IDPH never responded to her complaint, similar complaints can be found in previous state reports. Within the past four years, at least four IDPH surveys of the facility detail a failure to ensure call lights were in reach for residents.
Paying for Care
How does a resident end up at a home like Belhaven?
Preston said one reason is the payment procedure. When arriving at a facility, Medicare is going to cover 100% for the first 20 days. The next 80 days, Medicare will cover 80%.
However, after that Medicare funding runs dry, families need to apply for public aid. Preston said it can take six months to a year to get loved ones approved. And in the interim, few homes accept pending Medicare funding.
But Belhaven does, “and that’s where the problem comes in,” Preston said.
Preston tried to create change within the home while her brother was a resident, but said she was met with resistance. She became the president of Belhaven’s family council, a group of residents’ family members who try to reform care.
But instead of resulting in more oversight, Preston alleged management kicked her brother out of the home without proper reasoning — a practice known as hospital dumping.
“They took him to the [Veterans Affairs hospital] and left him and would not go back for him and would not let them send [him] back,” Preston said.
Just a six-minute walk away at Smith Village, residents of the three-star home are offered striking services: a movie theater, a salon and spa and a dinner menu offering filet mignon cooked at a resident’s desired temperature.
Medicare gives Smith Village a three-star overall rating and a five-star staffing rating. It’s a nonprofit home that services a population of people who are majority White and privately paying. In 2021, the skilled nursing section of the home reported having 42 residents.
In operation for almost 100 years, the home offers both independent and assisted living. Smith Village describes itself as a “a secure, inclusive place that affords you the opportunity to explore the new, rekindle old passions, and forge connections with warm and caring people.”
But even a higher-rated home gets complaints to IDPH.
In reports from 2019 to 2022, Smith Village has been cited for more than $79,000 in state fines and more than $126,000 in federal fines.
Advocates say staffing is at the heart of the issue of inadequate care for most homes across the city.
“Enormous racial disparities in the qualities of care,” said Meltzer, formerly of advocacy group Illinois Citizens for Better Care. “They’re less enormous and not because the Black homes have gotten better, but because some of the majority White homes are not as good as they were because of staffing issues.”
Even highly-rated homes see their care questioned by IDPH.
In one IDPH survey from January 2022, the facility failed to report a fall with a serious injury and death to the state.
Per the report, a resident was found lying on the bathroom floor with blood and a gash to the back of the head. Though emergency medical services were called and the resident was sent to the hospital, they died shortly after arriving.
When an IDPH official asked for the report, the home’s executive director stated that Smith Village “didn’t have to report that incident, R39 died at the hospital from cardiac arrest.” The associate executive director told the surveyor that “they were told by their consultant that this incident was not reportable.”
Later in the report, the surveyor writes that a resident under the same name had several falls during their time at the home, yet the facility did not put any interventions in place to prevent or minimize the resident’s falls and to avoid serious injury.
Smith Village officials did not immediately return a request for further comment.
Legislative Hopes Dashed
There was a renewed hope for improvement among advocates and residents when the 2010 nursing home reform law was passed. The amendment built on the existing 1979 Nursing Home Care Act — a consumer rights statute to protect residents’ rights in Illinois.
That 159-page bill updating the law attempted to address everything from raising the floor for staff-to-resident ratios to state oversight to creating designation for distressed facilities.
But hope has fizzled as implementation of the landmark legislation is falling flat.
“We would not be confronting the same issues 13 years later [if the legislation was effective],” said former state Sen. Jacqueline Collins, a Democrat of Chicago, who pushed for the reform.
“Ultimately, if you enforce the law, the quality of care would meet a legal standard across the board,” Meltzer said.
But some nursing homes are not meeting the minimum staffing numbers as required by the 2010 law.
Per the bill, effective Jan. 1, 2014, minimum staffing ratios were increased to 3.8 hours of nursing and personal care each day for a resident needing skilled care, and 2.5 hours of daily nursing and personal care for a resident needing intermediate care.
Within the available data from CMS and IDPH, about 32% of homes in Chicago are not meeting the minimum 2.5-hour requirement for residents.
In response to these figures, IDPH said there are “several factors that have affected the implementation of the staffing requirements starting with a lengthy rules making process in which the nursing home industry pushed for rules that were advantageous to the industry.”
In addition, under an amendment to the law passed in early 2023, the fines tied to the state’s minimum staffing requirements were delayed by two and a half years to July 1, 2025.
The department said a “larger issue of state hiring challenges and national staffing shortages has impeded IDPH’s ability to hire more surveyors, however the department is in the process of hiring additional surveyor staff to meet requirements.”
The state’s health department, too, continually falls short of legal staffing requirements for its home surveyors, the people who conduct inspections and complaint investigations. Per the 2010 law, at least one surveyor should be employed for every 300 licensed long-term care beds in the state. All surveyors should have been hired and trained by the end of the calendar year 2015, according to Long Term Care Facility reports from IDPH.
Yet, when comparing the number of beds to nursing home surveyors, the state is currently behind its legal requirement.
According to IDPH records, as of 2022 there were 104,420 licensed and/or certified beds in the state. That year, the state employed 187 surveyors — about 161 surveyors short of the requirement. It’s a goal the state has continued to miss since the law went into place.
In response, the department again pointed to the national staffing challenge for nursing homes.
Another integral piece of the 2010 reform package was the creation of a designation of distressed facilities. This piece of the law requires IDPH to generate and publish a quarterly list of nursing homes that were considered “distressed.” IDPH would establish a mentor program for owners of distressed facilities, as well as establish sanctions against facilities that don’t comply with the act.
Again, IDPH has not followed through with this. Thirteen years after the bill’s passage, the Illinois House approved a plan to clarify which nursing homes meet a distressed facility designation.
In response to this, IDPH said the department is in the process of completing the administrative rules the Distressed Facilities legislation requires.
“If you have a really crappy nursing home, you can impose additional requirements and additional supervision and make them hire a consultant to help fix it up,” Meltzer said. “And they’ve just never done it.”
No Compensation for Victims
Levin has been advocating for residents since there were just a handful of lawyers working on nursing home-related cases nationwide.
In his decades-long experience, he says the most pressing issue now is that nursing homes in Illinois don’t require liability insurance — which would mandate the person responsible for damages to pay for the damage they caused.
Though lawyers “perfected the art of discovering what nursing homes do wrong,” Levin said, victims aren’t actually receiving financial compensation due to this lack of insurance.
“[Homes] started to cut back on things like insurance, so a substantial amount of nursing homes are operating with grossly insufficient insurance or no insurance at all,” Levin said.
Before or during litigation, a nursing home being sued can transfer the operating company to another entity, according to Levin. That company being sued can then say that they’re out of business and therefore don’t have assets that can be collected.
Though it’s effectively the same residents and staff, Levin explained, “You can’t collect against them because they weren’t the licensee at the time your client was a resident.”
This loophole, he said, has led to a backlog of hundreds of lawsuit winners in Cook County and throughout Illinois with nowhere to turn to for financial compensation.
“It’s no different than a 20-year-old drunk driver who killed someone and you go to sue them and they say, ‘Sorry, we don’t have insurance and we don’t have any money — you’re out of luck,’” Levin said.
Levin is teaming up with other lawyers to try to require homes to have insurance. The lawyers are currently meeting with legislators to push for this.
“Homes shouldn’t be allowed to have the licensee transferred until some of these financial responsibility topics I’m addressing are met,” Levin said.
It’s strenuous work advocating for a loved one in a nursing home. That can involve working alongside an ombudsman who will “work their butts off” for families but can only serve as an advocate, Preston said. However, if a family goes the complaint route through IDPH with a specific issue, in her experience, Preston said “they’ll say they don’t see it.”
Nursing homes are as effective as a family member demands them to be, she said.
Since her brother’s departure from Belhaven, Preston has moved on to national work. She heads the Regional Family Council Consortium Network, a national group that hosts seminars and other talks to increase public awareness about abuse in homes.
“They work through us, they really try to advocate for their family members — they are concerned about their family members,” Preston said. “And people should receive quality care across the board — not because they have the resources to do so, but because it’s a human dignity issue.”