Closed Illinois nursing home was cited for deaths, sewage backup, mice
A local nursing home has closed after losing public funding because of substandard care and the conditions inside its building.
Before the closure this month, regulators cited Well Care Home of Maryville for a preventable resident death and other injuries, a sewage backup, rodent infestation and more issues uncovered during inspections between November 2024 and March 2025.
The nursing home received the most serious citation available to regulators in three of its last eight inspections: a determination that residents’ health or safety was in “immediate jeopardy.”
On April 2, federal regulators terminated Well Care Home of Maryville from Medicare and Medicaid, public insurance programs for people who are 65 or older and those with limited income. Medicare and Medicaid are the largest funding sources for long-term care service providers like nursing homes.
Termination is typically a last resort after working with providers to come back into compliance with regulations, the Centers for Medicare and Medicaid Services — the federal regulatory agency for nursing homes — said in a statement to the Belleville News-Democrat.
Three years ago, the nonprofit nursing home New Athens Home for the Aged also closed after it was terminated from Medicare and Medicaid.
Well Care Home of Maryville notified its 73 residents and their families that they needed to find alternate care and gave them four local options to consider, including one of its owner’s other long-term care facilities, according to communications with the Illinois Department of Public Health obtained through a public records request.
The nursing home informed state officials that it planned to terminate all 60-plus employees when Well Care Home of Maryville closed.
The facility is located at 152 Wilma Drive in Maryville and used to be called Elmwood Nursing and Rehabilitation Center. It was rebranded in 2024 after it came under new ownership.
Dr. Ahsan Usman, a local physician, bought the property last summer for $1.6 million through the company Au Well Care Home Inc., whose address is Usman’s O’Fallon home, county property records show.
Usman also owns nursing homes in Highland and Breese, according to information from state and county records related to the properties.
He bought and reopened the former Faith Countryside Homes nonprofit nursing home and assisted living facility in Highland, which closed in 2021 due to financial issues. Today, it operates as Well Care Home of Highland. Usman also owns Breese Nursing Home, which was one of the placement options given to former Well Care Home of Maryville residents.
Neither Usman nor the Well Care Home of Maryville administrator responded to the BND’s requests for comment.
They told Illinois Department of Public Health inspectors about the challenges they faced running Well Care Home of Maryville, according to interviews detailed in inspection reports provided to the BND by the Centers for Medicare and Medicaid Services.
Many residents had mental health issues causing aggressive behaviors, and they would get into fights. The facility was short-staffed and missing key personnel at times, including a director of nursing and a maintenance worker. And it was an old building — constructed 58 years ago in 1967 — with persistent plumbing problems.
“I am putting out so many fires here,” the administrator told a state inspector in a January interview about why she didn’t submit a report on her investigations into resident reports of verbal and physical abuse.
Resident deaths, fight injuries scrutinized
An emergency room nurse told a state inspector that a Well Care Home of Maryville resident’s death was preventable if the nursing home staff had emptied his catheter in a timely manner, according to a recent inspection report.
The resident died in the hospital in December after being admitted in serious condition with septic shock, acute kidney injury when he already had chronic kidney disease, urinary tract infection, and encephalopathy, which causes brain dysfunction.
In an interview with the inspector, the administrator said she was “very unhappy” with the care provided to that resident.
“I can tell you it has a lot to do with lack of nursing oversite (sic) and nursing judgment,” the administrator said, according to the inspector’s December report.
Another resident, who died in December after being hospitalized for pneumonia, hadn’t received any pneumococcal vaccines since he was admitted in late 2023, according to the state’s inspection.
He was one of 33 residents who were overdue for the pneumonia vaccine, according to a February report. Other residents said they never received updated flu or COVID-19 vaccines after requesting or consenting to them.
The assistant director of nurses told an inspector in late January that she had been meaning to give vaccines before then, but had been waiting for a while for needles.
Inspections also scrutinized resident injuries from fights at Well Care Home of Maryville.
A certified nursing assistant was accused of biting a resident’s finger and causing a facial laceration and black eye in a physical altercation in March. The state inspector cited the nursing home for failing to initiate an abuse investigation and remove the CNA from the facility. The CNA continued working for the remainder of her shift.
Two days after that altercation, a licensed practical nurse was accused of telling the resident he wasn’t going to allow her to attack another female staff member and if she did, he was going to beat her to death. The inspector wrote in a March report that the administrator didn’t notify authorities of a death threat made by a nurse.
Inspectors also wrote the facility up for failing to prevent resident-on-resident abuse. One resident was flipped from his wheelchair, hit in the face and grabbed on the arm by three other residents, according to the March inspection report.
Another resident also punched a resident who had dementia and wandered into his room, causing a black eye and nosebleed, the February inspection report states. The two residents had previously had a physical altercation. The administrator told an inspector that one of them should have been moved to a different hallway but they continued to reside in rooms on the same hallway across from one another.
A leg amputation, other issues caused by substandard care
The March inspection at Well Care Home of Maryville found that the staff didn’t know a diabetic resident had developed an ulcer on her foot because they didn’t do weekly skin assessments like her physician ordered. She was hospitalized for 17 days after complaining of excruciating foot pain in late February.
A severe infection in her foot ultimately required doctors to amputate her left leg above the knee.
The staff delayed hospitalization for another resident who had pneumonia and COVID-19 while she experienced symptoms of coughing and difficulty breathing because they didn’t know her chest X-ray results were available for five days in January. The administrator thought it was because the fax machine is in a separate office that staff may not have been checking, according to the February inspection report.
The February report also states that staff didn’t attempt to schedule a follow-up appointment with an orthopedic surgeon for a resident with a hip fracture, which the hospital emergency department recommended in January.
The staff also didn’t notify the medical director immediately when a resident began not eating, being slow to respond, having tremors and grimacing when touched in December, according to the March inspection report. The resident had highly elevated ammonia levels that required hospitalization for 42 days and intubation in the intensive care unit. The resident was diagnosed with decompensated cirrhosis, hepatic encephalopathy, urinary tract infection, and pneumonia.
A resident whose ability to walk was declining because of Parkinson’s disease fell down 10 times in about a month between October and November, causing fractured ribs, a laceration to his face and bruising to his right eye, according to a January inspection report. His medical records documented that he wouldn’t ask for help from staff. The nursing home was cited for not trying any new measures to help him from falling.
Well Care Home of Maryville also received citations for failing to treat residents’ mental illnesses.
During the March inspection, two residents were suicidal and another resident was injuring herself, throwing feces and objects at staff and abusing another resident.
A month earlier, a licensed practical nurse was fired after being accused of not addressing a suicidal resident yelling and hitting her head on the wall in her room, instead closing the double doors on her hallway to stifle the noise.
“I don’t see why state doesn’t shut this place down,” one resident told an inspector, according to the February inspection report.
They spoke in late January, when about 40 residents didn’t receive their morning medications because a day shift nurse called off work. Some residents also reported not receiving afternoon or evening doses of their medicine. The medication error was considered significant, causing elevated heart rate and blood glucose levels, as well as anxiety in residents, according to the report.
Inspectors also cited the nursing home for failing to keep contagious infections in check. A gastrointestinal illness spread from two residents in early January to five more residents.
The facility had no documentation that it conducted any COVID-19 testing or contact tracing to determine possible close contacts when two residents and an employee got COVID in late January.
Nursing home had sewage backup and rodent infestation
At the beginning of January, a plumbing backup exposed residents to sewage, which contains bacteria, viruses and other potentially harmful substances.
An inspector observed sewage-contaminated water pooling in the shower room, a hallway and in 18 residents’ rooms.
Residents reported to the inspector that cleanup after the issue was insufficient because cleaning crews didn’t wipe down walls and baseboards or mop under some furniture. And they detailed other concerns with cleanliness and plumbing outside of the sewage backup. Utility room sinks covered with trash bags had black-colored water sitting in them, the residents said.
The administrator told the inspector she was not aware of the issue with the sinks because no one notified her.
More plumbing issues were noted in three other inspections. A toilet was leaking in two residents’ shared room in December. And in January, a pipe was leaking in the basement and the entire facility was without hot water for weeks.
The facility also had a rodent infestation in January, according to an inspection report.
During Jan. 23 interviews, residents told the inspector there had been mice inside the building for one and a half or two weeks, and it was not the first time mice had been in the facility.
The inspector noted that staff were using boxes of reduced sugar nutritional supplements on the floor to prop open double doors to the hallway where mice were reported. The administrator told an inspector Well Care Home of Maryville is not a clean facility and suggested the owner may not have renewed its pest control contract to provide monthly services when he took over.
Regulators had said the Well Care Home of Maryville residents could continue receiving payment for services for an additional 30 days after the April 2 termination from Medicare and Medicaid. But Illinois Department of Public Health spokesperson Mike Claffey confirmed Monday the facility closed its doors well ahead of that timeline.
“Under these circumstances, it was in the best interest of patients to have them relocated to alternate and safe accommodations as quickly as possible,” Claffey stated in an email to the BND. “IDPH was onsite monitoring the closure process (the week of April 2) and will continue to work with any of the former residents who need assistance to ensure that they are able to find acceptable long-term solutions to their needs.”
