Juanita Simmons’ sisters said they repeatedly saw signs of physical abuse before she was found dead, strapped to her wheelchair at the bottom of a flight of stairs at a Belleville nursing home.
Ruth McCray and Loretta Jean Ulmer said they visited their older sister every week and saw bruises on her face, a black eye and stitches inside her mouth.
“I was afraid for her,” McCray said. “She hated it there and they weren’t good to her.”
The St. Clair County Coroner’s Office has an “open and active” investigation into the death of Simmons, who was found dead Thursday morning at Midwest Rehabilitation and Respiratory Center, 727 N. 17th St. in Belleville. Nursing home administrator Rebecca Garcia could not be reached, and previously declined comment.
“I have had my guys out there. They will return. They are working with state investigators and will continue to do so until we get to the bottom of the circumstances of this death,” Coroner Rick Stone said.
Simmons, 85, had to pass through a heavy fire door to get to the stairs.
“We were told that it was very hard to open,” Ulmer said. “Even if it was, it should have had an alarm on it.”
Ulmer and McCray visited their sister every week. Both said they wanted Simmons moved from Midwest, but neither had the legal authority to move her. The family member with that authority could not be reached.
In January 2013, McCray said she went to Simmons’ room to visit. She saw a nurses’ aide push Simmons’ wheelchair down the hall, letting go of the handles, McCray said. When McCray questioned the aide’s actions, the aide told her, “We were just having fun.”
“I told her, ‘That’s poor fun,’” McCray said.
When they visited Simmons in the past, Ulmer and McCray said they saw a black eye. As proof they showed a photo of Simmons dated Oct. 7, 2010, which would have been a short time after Simmons moved into the nursing home. Ulmer said she was told by staff the black eye happened when Simmons was being transferred from her bed into her wheelchair and fell.
Another time she had a string hanging from her mouth that turned out to be a remnant of stitches in her mouth from being hit in the face by a sugar bowl thrown by a male patient. Ulmer said it was the same man who once stabbed Simmons in the arm with a fork.
Ulmer said she called the state’s nursing home hot line at least 10 times to report suspicions about Simmons being abused. The state keeps those calls confidential and would not confirm there were calls about Simmons.
State inspection reports noted violence between residents that included kicking, hitting and, in one incident, a resident pulling another resident out of a wheelchair, causing a fractured shoulder. State reports also stated residents said there wasn’t enough staff to properly administer care, with there being only four nurse’s aides to provide care for up to 180 patients.
Nursing home personnel called 911 at 6:32 a.m. Thursday for an ambulance but did not request police, Belleville Police Detective Sgt. Mark Heffernan said.
“We did not learn about the suspicious circumstances surrounding the case until after the coroner’s office was involved,” Heffernan said.
Simmons’ body was transferred to a funeral home in Montgomery County. The funeral home director, who was contacted by Simmons’ daughter, called the St. Clair County Coroner’s Office to ask what type of death certificate was to be issued. Coroner’s office personnel told the funeral home director they were not notified of the death. In the case of an accidental death, the coroner’s office must sign the death certificate. Simmons’ body was then returned to St. Clair County for an autopsy.
In the past year, the Illinois Department of Public Health, the agency responsible for inspecting nursing homes, received 20 complaints against Midwest.
Among the substantiated complaints:
Failure to make an incident report when a nurse’s aide transferred a patient on a ventilator alone, knocking out his breathing tube. The patient received emergency treatment at the facility, then was transferred to a local hospital.
Improper handling of medication, including giving a male resident with schizophrenia and sexual compulsive disorder a female hormone typically used to prevent pregnancy. A state regulator found no prescription for the medication and no rationale to give it to the resident.
Failure to address a plan to handle patients wandering from the facility. This came after two men wandered away in 2012. Joseph E. Childs, who suffers from schizophrenia and bi-polar disorder, was found by Midwest Rehab staff members at the Flying J truck stop in Alorton in March 2012. In January 2012, 77-year-old Aubrey Giles walked away from the home and was found dead two days later in a heavily wooded creek about a block from the nursing home.
While nurses’ aides and nurses responded promptly when patients hit the “call light” button, the response was often that the light was simply turned off and no help was forthcoming, sometimes for hours. Patients were required to wait to be helped to a toilet or for medical assistance.
On Jan. 29, according to a state report, an elderly patient noticed that her roommate, another woman, was having a seizure. She pushed the call light button for the woman but no facility employee responded for 40 minutes. When help finally arrived, the report noted that an ambulance was called and the woman having the seizure was sent to a hospital emergency room. There was no information about whether she survived her medical emergency.
The same report states in a paragraph immediately after this narrative about a review of the minutes of a meeting of the “Resident Council,” which is made up of patients. According to the minutes, the staff, “Does not pass out meal trays” in a timely manner, hide their name tags and sleep on duty. During another meeting with patients this year, a state inspector reported being told that there is often, “Only one CNA (certified nursing assistant) to care for 300-400 hall residents.”
Ulmer said she saw evidence of this herself, probably last year, when Ulmer said she tried to get a staff member to change her sister’s feces-fouled underwear before supper but was ignored.
“Juanita said, ‘I need my pants changed. I need my pants changed. Please.’”
Finally, Ulmer said she stopped a nurse’s aide and asked why her sister wasn’t being helped and was told, “I don’t have time.” Three hours later, Juanita was still in distress, Ulmer said.
About two months ago, Ulmer said another resident who was friends with Juanita, warned her and another family member.
“Every time I went there, I just cried,” Ulmer said. “It takes 10 years off my life every time I went to see her.”