State and federal regulators have issued $1.3 million in fines to 16 metro-east nursing homes so far in 2025 for violations uncovered during inspections, according to government data.
The fines were issued between January and April, the latest available, and ranged from $500 to more than $580,000 per facility. The agencies responsible for inspecting nursing homes and determining penalties for violations are the Illinois Department of Public Health and the U.S. Centers for Medicare and Medicaid Services.
In the metro-east, inspectors cited nursing homes for incidents including physical and sexual abuse between residents, a resident’s leg amputation resulting from gangrene and a bone infection, a bedbug infestation and additional issues.
A total of $286,200 in state fines correspond to specific inspection reports, which are dated based on when each inspection ended. Another $1,018,675 in federal fines were published using the same dates as those reports, but may also cover earlier inspections within the same federal “enforcement cycle,” according to a CMS spokesman.
Here is a look at the violations and fines at each facility. The Belleville News-Democrat included information only about nursing homes that remain open and noted when facilities have come under new ownership or changed their names since the violations occurred.
Belleville Healthcare Center
(Now called Nexus Pavilion at Belleville)
727 N. 17th St., Belleville
Total fines: $583,085
Belleville Healthcare Center twice received the most serious citation available to regulators: a determination that residents’ health or safety was in “immediate jeopardy” after an elopement last December and a sexual abuse allegation in January.
Inspectors cited the nursing home for failing to monitor and supervise a resident who left the facility unattended for an hour and a half, from 2 a.m. to 3:30 a.m. on Dec. 20. He fell and sustained multiple abrasions to both legs, a dislocated left wrist and facial lacerations that required stitches, according to the inspection report.
Staff members denied hearing any door alarms sounding. The facility audited all of its door alarms after the inspection to ensure they were working properly.
Inspectors also cited the nursing home for failing to protect a resident from sexual abuse by another resident known to be sexually inappropriate with staff and residents.
The facility notified police and involuntarily discharged the resident accused of exposing himself and making another resident touch him.
Other violations:
- Failure to prevent physical abuse between six residents. This failure resulted in a subarachnoid hemorrhage and left orbital wall fracture for one resident when another resident pushed her and she fell face first to the floor. In other cases, residents pushed, hit, punched and threw a chair at others.
- Failure to ensure abuse was thoroughly investigated for two residents. Staff members said they saw one resident hit the other in the head. The administrator told an inspector their statements were inconsistent and suggested some employees lie, which made it “impossible” to determine if abuse occurred.
- Failure to prevent the development of additional bedsores for one resident. This failure resulted in two new sores.
- Failure to perform and document a head-to-toe skin assessment upon readmission to the facility for one resident. This failure resulted in the deterioration of a bedsore.
- Failure to maintain an effective pest control program to prevent a bed bug infestation in one unit of the facility.
- Failure to ensure physician visits were completed at least every 60 days for four residents. The director of nursing in January told an inspector he was not aware of the requirement.
- Failure to employ a full-time director of nursing in March.
- Failure to send a medical record in a timely manner for one resident.
- Failure to ensure garbage in the facility’s dumpster was covered. The administrator told an inspector the garbage truck operator ripped the lid off the dumpster and that the company said it would replace the unit.
Breese Nursing Home
(Now called Evercare of Breese and under new ownership)
1155 N. First St., Breese
Total fines: $160,195
Breese Nursing Home was also cited for “immediate jeopardy” after a resident developed gangrene and a bone infection called osteomyelitis, which led to the amputation of her leg.
Inspectors said the nursing home failed to monitor and treat a suspected deep tissue injury on the resident’s toe. Staff members first documented an area of concern on the resident’s toe on Aug. 20, 2024. They did not document any treatment until seven weeks later on Oct. 8, 2024, when the resident was hospitalized.
The wound nurse told an inspector she did not know about the resident’s toe in August because she did not see a message about it on a phone application the facility was using for staff communication. In early January, the facility audited its records to verify treatments were in place for all active wounds.
Inspectors also cited the nursing home for failing to staff a registered nurse for 10 days in January. The director of nursing told an inspector the facility hired a new RN, who started working Jan. 22.
BRIA of Alton
3523 Wickenhauser, Alton
Total fines: $29,400
- Failure to prevent physical and sexual abuse between five residents. Staff members reported seeing one resident inappropriately touching another resident, but both residents denied it happened. In other cases, residents hit and threw hot coffee at others.
- Failure to conduct an investigation and provide a final report for the thrown coffee amid administrator turnover.
- Failure to send a resident for evaluation and treatment after multiple refusals for dialysis. She was hospitalized in the intensive care unit as a result.
- Failure to provide a resident’s prescribed pain medication one day because the facility ran out of doses.
- Failure to notify a severely cognitively impaired resident’s legal guardian about her use of a narcotic for pain and refusing speech and physical therapy.
- Failure to offer a nighttime snack to at least four residents.
BRIA of Belleville
150 N. 27th St., Belleville
Total fines: $75,440
- Failure to administer a resident’s seizure medication for two days because the facility ran out of doses. She had four seizures and was hospitalized as a result.
- Failure to provide showers twice a week to at least three residents in January and failure to change one resident’s dirty incontinence brief one morning.
- Failure to provide palatable food at an acceptable temperature and failure to provide nourishing snacks between meals or at bedtime to at least four residents in January.
- Allowance of staff members’ use of cell phones in resident areas, against facility policy.
BRIA of Cahokia
3354 Jerome Lane, Cahokia Heights
Total fines: $29,400
- Failure to prevent verbal and physical abuse between eight residents. The residents threatened and hit others. This failure resulted in one resident’s fractured hip when he fell after initiating a fight.
- Failure to ensure all abuse allegations were thoroughly investigated for four residents.
- Failure to provide follow-up urology care per standards of practice. This failure resulted in a delay of one resident’s scrotal surgery and “ongoing unnecessary pain.” The social service director told an inspector she was new to the job and did not know why the resident had not gotten an appointment for his surgery.
- Failure to assess a resident’s skin upon admission, provide ongoing assessments, follow or update the physician’s treatment orders, complete physician-ordered bedsore treatments and put interventions in place to prevent skin breakdown for three residents. This failure resulted in one resident developing a deep tissue injury to his right hip, which worsened by increasing in size.
- Failure to treat a resident’s bedsores per physician’s orders for four days.
- Failure to implement progressive interventions to prevent falls, implement safe mechanical lift transfer techniques and ensure equipment is in good repair to prevent injury for four residents.
- Failure to maintain a clean and sanitary environment during wound care and wear personal protective equipment when caring for three residents.
- Failure to properly store six residents’ medications. Staff members left the medicine at residents’ bedsides when they were not in their rooms.
BRIA of Godfrey
1623 West Delmar, Godfrey
Total fines: $31,650
- Failure to ensure enteral gastrointestinal feedings and care were provided as ordered for three residents. This failure resulted in one resident being hospitalized for treatment of aspiration pneumonia related to food regurgitation.
- Failure to have physician-prescribed narcotic pain medication for a resident because the facility ran out of doses. The resident had severe pain, incontinence and aggressive behaviors as a result.
BRIA of Wood River
393 Edwardsville Road, Wood River
Total fines: $123,575
- Failure to assess, monitor and treat a resident’s change of condition. The resident was not eating and lost about 10 pounds in a week. She was hospitalized as a result.
- Failure to identify, assess and monitor bedsores and provide the physician-prescribed treatment for four residents. One resident developed multiple bedsores while at the facility, including one that became infected. Another resident developed a bedsore and did not receive treatment for 23 days.
Caseyville Nursing and Rehab Center
601 W. Lincoln Ave., Caseyville
Total fines: $4,400
- Failure to prevent a resident’s sexual abuse. Staff members found a resident lying on top of another resident.
- Failure to prevent the physical and verbal abuse of two residents. One resident alleged a resident grabbed her arm. Another resident alleged a CNA refused to clean him up and cursed at him. The administrator told an inspector that she did not see one resident grab the other on camera footage, but she reported the CNA to the agency he worked for and the licensing board.
Cedar Ridge Health and Rehab Center
1 Perryman St., Lebanon
Total fines: $2,200
- Failure to provide effective pain management during incontinence care for a resident with bedsores.
- Failure to provide treatment and services to prevent and/or heal a resident’s bedsores.
- Failure to provide feeding assistance to four dependent residents.
- Failure to follow a resident’s wound care orders.
- Failure to do timely and complete incontinent care for four residents.
- Failure to supervise a resident with cigarettes, safely transfer residents using a mechanical lift, and implement fall interventions for four residents.
- Failure to ensure a resident is free from significant medication errors. One resident missed doses of antibiotics for an infection.
- Failure to confirm the need for an antibiotic and ensure five residents received all doses as ordered.
- Failure to ensure resident call lights are within reach for four residents and provide dignity during feeding assistance. A CNA was standing over residents while assisting them with meals.
- Failure to serve food with an appetizing appearance and taste to at least seven residents. One resident described the facility’s food as nasty.
- Failure to perform handwashing and glove changes while caring for six residents.
Eden Village Care Center
400 S. Station Road, Glen Carbon
Total fines: $500
- Failure to ensure timely and complete incontinent care was done for four residents.
- Failure to perform proper handwashing and glove changes were done during incontinent care and sanitize glucometer between residents during medication pass for four residents.
- Failure to prevent skin breakdown for two residents with bedsores.
- Failure to check if employees had a prior criminal history, which would disqualify them for employment, before hiring at least seven people.
- Failure to label food items in the refrigerator with use-by dates and dispose of outdated food items.
Evercare at Edwardsville
401 St. Mary Drive, Edwardsville
Total fine: $500
- Failure to prevent physical abuse between four residents. Residents pushed, struck and threw a cup of iced tea at others.
- Failure to check if employees had a prior criminal history before hiring at least seven people.
Evercare at University
1095 University Drive, Edwardsville
Total fines: $103,650
- Failure to monitor and assess a diabetic resident’s blood sugar levels. The resident was hospitalized, requiring emergency intervention for a “critically low blood glucose level.”
- Failure to implement interventions to address a resident’s significant weight loss. The resident experienced a weight loss of 20% over a four-month period, dropping from 170 pounds to 136.
- Failure to notify the physician of a resident’s weight loss and blood glucose readings.
Evercare of Collinsville
614 N. Summit, Collinsville
Total fines: $1,100
- Failure to ensure timely assessment for continuity of care for one resident. This failure resulted in a resident with known epilepsy with seizures not receiving medications for four days, having a seizure and being sent out for emergency treatment. A nurse practitioner ordered a hold on the resident’s medication due to a report from the nursing staff that it was possible she was being double or tripled dosed by her daughter.
- Failure to ensure a resident with a diagnosis of epilepsy with seizures received his anti-convulsant medications as ordered by the physician. The resident missed 10 doses when the facility ran out.
Friendship Manor Health Care
485 S. Friendship Drive, Nashville
Total fine: $2,200
- Failure to prevent the verbal and mental abuse of at least four residents. A certified nursing assistant was accused of being impatient and rude to residents when they needed help dressing and getting out of bed and refusing to help them shower. The administrator fired the CNA after an investigation.
Granite Nursing and Rehabilitation
(Now called Evercare of Granite City and under new ownership)
3500 Century Drive, Granite City
Total fines: $25,000
- Failure to notify the nurse a resident was not feeling well to ensure timely assessment. Because a nurse was not available, a certified nursing assistant left the resident at the empty nurse’s desk to answer a call light. The resident became unresponsive while waiting for the nurse because her oxygen tank was empty. She was hospitalized after staff members revived her with CPR.
- Allowance of a certified nursing assistant administering oxygen to a resident.
St. Paul’s Senior Community
1021 W. E St., Belleville
Total fines: $132,580
- Failure to ensure respiratory care needs met current standards of practice for five residents. A resident with COPD did not receive ordered nebulizer treatments and experienced chest pain and tightness, shortness of breath and decreased oxygen saturations.
- Failure to provide oxygen to an oxygen-dependent resident.
- Failure to provide sufficient staff to care and tend to at least four residents’ needs.
- Failure to maintain residents’ pride and dignity. Two residents said they were left waiting to be taken to the bathroom or get cleaned up after a bowel movement.
- Failure to provide timely and complete incontinent care for two residents.
- Failure to ensure a resident’s pain medications were available and provided.
- Failure to safely transfer a resident from a bed to a wheelchair.
- Failure to notify a family representative of a resident’s significant illness from pneumonia.
- Failure to ensure food was stored and prepared in a manner which prevents potential contamination.
- Failure to submit required staffing information for the fourth quarter of 202
BRIA Health Services owns and operates Belleville Healthcare Center, BRIA of Alton, BRIA of Belleville, BRIA of Cahokia, BRIA of Godfrey and BRIA of Wood River. BRIA CEO Daniel Weiss did not respond to a request for comment about the 2025 fines and violations.
Evercare Skilled Nursing owns and operates Breese Nursing Home, Evercare at Edwardsville, Evercare at University, Evercare of Collinsville and Granite Nursing and Rehabilitation. Evercare CEO Yehuda Rosenblatt did not respond to BND requests except to clarify that the company did not own Breese Nursing Home or Granite Nursing and Rehabilitation at the time of the early 2025 inspections.
Leaders at Caseyville Nursing and Rehab Center, Cedar Ridge Health and Rehab Center, Eden Village Care Center, Friendship Manor Health Care and St. Paul’s Senior Community also did not respond.
Editor's note: This story was originally published by the Belleville News-Democrat, a news partner of St. Louis Public Radio.
