A newly released state report details the last moments of Juanita Simmons’ life, just before she went down a flight of stairs in her wheelchair and was found dead with a bruised face and bloody, gashed head.
State investigators completed their investigation into the death of the 85-year-old Simmons, who suffered from dementia, and was found March 12 at about 6:30 a.m. by an nurse’s aide coming in to work at Midwest Rehabilitation and Respiratory at 727 N. 17th St. in Belleville.
The state investigators’ report stated the facility must ensure that the home remain as free of accident hazards as possible and each resident receives adequate supervision and assistance to prevent accidents. The investigation revealed that alarm’s volume for the stairwell door was turned down. It since has been increased and changed to an “instant loud shrill that can only be turned off by entering a numerical code on a key pad at the top of the door.”
“The thing I have to say, why was the alarm turned down and why wasn’t the door locked?” said Simmons sister, Loretta Jean Ulmer, upon reacting to the report.
Midwest Rehab Administrator Becky Garcia declined to comment.
Ulmer hopes the findings answer some questions surrounding Simmons’ death. “We didn’t know how. We don’t know who found her,” Ulmer said. “There are so many things.”
According to the Illinois Department of Public Health investigation:
• 5:49 a.m. Simmons is seen on videotape leaving the dining room.
• 5:56 a.m. Simmons is seen in a wheelchair facing the vending machines near the doorway leading to the staircase.
• 5:58-6:08 a.m. Simmons remains in the vending area.
• 6:08 a.m. Simmons is seen turning toward the stairway. At this time, the camera loses sight of her.
• 6:16 a.m. Another resident, identified in the report as R5, is seen exiting the elevator and walks toward the stairwell, then the two are out of camera view. State investigators asked her if she saw Simmons go through the door to the stairwell between 6:15 and 6:20 a.m., and the female resident refused to answer.
• 6:32 a.m. Belleville police dispatch receives a call from the nursing home.
• 6:35 a.m. Ambulance report stated, “Disposition: Dead prior to arrival.”
Staff told state investigators that they found Simmons around 6:30 a.m. “laying on a platform down a flight of about six to eight stairs with a small puddle of blood around her head and the wheelchair on top of her.”
State investigators attempted to contact the certified nurse’s aide who found Simmons, but were unsuccessful. They referenced a written statement from the CNA, who is identified in the investigation as E8.
“I came in the side entrance and found (Simmons). I felt for a pulse. I couldn’t get one. I jumped over Simmons and ran to the door and screamed for a nurse. Simmons was face down. We were trying to get the wheelchair off her. A nurse gave me scissors to cut her seat belt. We took the chair off and rolled her over. … I laid down next to Simmons to see if I could get a pulse.”
The same employee said that the alarm on the door to the steps sounded when she opened it.
Ambulance crews noted a large gash on her head. The report stated the patient was pale, cool and dry, and had bruising around the eyes with no pulse and no breathing.
After the paramedics determined Simmons had died during the fall, the ambulance crew left her at the scene and told the nurses to call the coroner.
But the coroner was not contacted, according to St. Clair County Coroner Rick Stone, until after Simmons’ body was taken to a Montgomery County funeral home. Deputy Coroner Dean Darnell retrieved the body and brought it back to St. Clair County for an autopsy. Darnell told state investigators that Simmons died as a result of blunt force trauma and possibly a broken back.
“I would tell them to hire more people, train them better and be more vigilant,” Stone said. “After all, this is someone’s loved one.”
Melaney Arnold, a spokeswoman for the Department of Public Health, said the state agency is still trying to determine whether a state license violation will be issued.
“Because IDPH conducts investigations on behalf of the federal CMS (Centers for Medicare and Medicaid Services), we can recommend a fine, but CMS has the ultimate say,” Arnold said. “We have not heard from CMS yet on this situation. “The fine amount is also impacted by other factors, such as the facility appealing the fine.”
The agency showed $28,500 in fines were imposed on the nursing home in the last three years.
Midwest Rehabilitation and Respiratory, formerly the Calvin Johnson Nursing Home, is operated by Senior Healthcare Management in Skokie, Ill., near Chicago. The principal investor is Steven Blisko, 34. Senior Healthcare Management operates nine nursing homes in the metro-east and Southern Illinois that, like Midwest Rehabilitation, have a one-star rating, the lowest rating given by Medicare.