The inspectors knew there was trouble as soon as they entered the nursing home.
The lobby smelled of urine. In one room, they found a 97-year-old woman, lying in her own waste. She had severe bruises on her arm, foot and both legs that the staff could not immediately explain. Another resident had a bed sore larger than a golf ball and dripping blood.
This was life in one of Illinois' "one-star" nursing homes.
These health violations—and two dozen more—were documented last year on a single inspection of the Berwyn Rehabilitation Center, contributing to its dubious distinction as one of the area's worst nursing homes.
The federal government is now rating nursing facilities on a 1 to 5 star system. Although conditions at one-star homes are startling, what is perhaps more alarming is their prevalence: About a quarter of U.S. nursing homes, including 81 in the six-county Chicago area, received one star.
A government Web site began posting ratings on these homes in December. Nursing home operators and even some patient advocates have criticized the rankings as superficial and perhaps misleading. And the detailed information behind those ratings is not readily available to the public.
But the Tribune obtained the most recent inspection reports for the area's lowest-rated homes through a Freedom of Information Act request. The conditions described are grim and, at times, deadly—as the Berwyn facility demonstrates.
Last March, inspectors found workers there were improperly using side railings on beds. Four months later, records show, a 53-year-old obese resident suffocated when he got stuck between the mattress and side rails. Illinois fined the facility $50,000 for the death, one of the largest nursing home penalties in the state last year.
A top administrator at the Berwyn facility acknowledged that, until recent months, care was poor.
"This nursing home was really bad," said Anjanette Miller, the director of nursing hired in May to oversee patient care. Workers, she said, "were punching in and doing nothing."
Since last spring, Miller said, the home has been under new management. "It's like night and day as far as improvements go," she said, "The bad, bad employees we got rid of."
According to records, all major violations found during the annual inspection last March had been corrected as of June.
But the man who suffocated did so in July—weeks after Miller and new management took over. She would not comment on that other than to say, "Accidents do happen."
State authorities said the for-profit home is owned by Berwyn Rehabilitation Center LLC. (The facility changed its name in May from the Pinnacle Health Care of Berwyn to the Berwyn Rehabilitation Center.)
One-star nursing homes meet minimum standards but are considered "much below average," according to the federal rating system. Inspection reports of those facilities show the daily despair many residents face.
At the Embassy Care Center in Will County, residents last fall complained of cold food, staff not answering calls for help, loud employees keeping them up at night, and workers not relaying phone messages from family members.
Residents said that when they voiced concerns, staff responded at times by pointing to the cemetery across the street. State investigators cited the nursing home, concluding that residents could not speak up without fear of reprisal.
When the Tribune asked the nursing home's administrator, Sue Bessette, about the residents' complaints, she said: "Yes, we were cited, but those things did not happen. Anybody can say anything." She would not comment further.
One of the area's most troubled nursing homes has been the Berwyn facility, according to a review of the most recently available government records.