South Shore Nursing Home Repeatedly Cited for Understaffing and Resident Neglect

This story is co-published with the Hyde Park Herald.

Gladys King-Lucas temporarily moved into the Symphony South Shore nursing home and rehabilitation center in mid-March to recover from a broken hip. But since coming to the home, her daughter, Chiesa Lucas, alleges that her 75-year-old mother hasn’t been acting the same.

Walking through the third floor of the facility, where her mother’s room is located, Lucas points out visibly dirty chairs and chipping wall paint. In Lucas-King’s room, she sleeps wrapped in a thin blanket without floor cushions to minimize injury if she falls. 

“It’s like a waiting room to die,” Lucas said.

Over the course of her mother’s four-month stay, Lucas reported these complaints to the Illinois Department of Public Health (IDPH),  the state agency that regulates nursing homes. However, according to the department’s complaint determination form, after an inspection on April 10, IDPH found no violation of resident rights, housekeeping or short-staffing. 

But Lucas is not alone in her complaints of the home. In reports from 2019 to 2021 collected by the IDPH, Symphony South Shore has been cited for repeated cases of resident neglect, lack of properly enforced safety protocol and COVID-19 spread. At times these cases, linked in IDPH reports to understaffing and poor managerial oversight, have resulted in physical harm to residents and more than $86,000 in fines. 

Medicare, the federal agency that evaluates nursing homes, has rated the home’s performance one out of five stars on the basis of health inspections, staffing and quality measures. According to the agency’s portal, which evaluates facilities nationwide, Symphony South Shore is “much below average.”

Symphony South Shore was opened in 1998 at 2425 E. 71 St, and is part of a chain of for-profit nursing homes and assisted living facilities within the Symphony Care Network. There are twenty-four homes in the network across Illinois, Indiana and Michigan, though most are located in Chicagoland. Annually, the network generates more than $440 million in revenue.

Symphony South Shore is owned by brothers David and Mark Hartman, who also co-own multiple other locations. David Hartman, former CEO of Symphony Care Network (he stepped down in late-2021), owns 50% of Symphony South Shore, as well as has ownership interest in sixteen other homes. Mark Hartman owns 12.5% of Symphony South Shore, and shares ownership of fourteen of David’s homes.

Breaking down the Medicare rating for each of David Hartman’s homes, facilities on the North Side of Chicago or in wealthier suburbs fare better than Symphony locations on the South and West sides. Six of David Hartman’s homes that are three out of five stars—or higher—all have a majority white population, and are located in places like Lincoln Park, Evanston and Buffalo Grove. However, nine of Hartman’s homes are either one or two stars, seven of which have a majority Black population and are located in places like South Shore, Bronzeville and Austin. 

A spokeswoman for Symphony South Shore did not comment on this.

Per IDPH and Medicare reports, numerous repeated cases of neglect contributing to the low rating involve staff failure to follow COVID-19 mitigation protocol, such as wearing proper PPE.  By late-April of 2020, a little more than one-month into the pandemic, the Symphony Care Network reported that more than seventy percent of residents in the South Shore facility had been infected with COVID-19, resulting in 10 deaths. As of June 21, thirty-three residents and one staff member have died of COVID-19.

In three IDPH reports from May 2020 to Feb. 2021, the facility failed to ensure either staff or residents were properly wearing masks or any form of face covering. In one report from May 21, 2020, a Licensed Practical Nurse (LPN) was observed at the nursing station without any form of face covering. That same day, the director of nursing stated that the facility has enough face masks and PPE and there is “no reason for anyone to be without a face mask.” However, later in the day another LPN and a Certified Nursing Assistant (CNA) were observed not properly or not at all wearing a mask.

The May report noted that this affected all thirty residents on the first floor, fifty-four residents on the second floor and thirty residents on the fourth floor. The facility said in the report the affected employees were counseled on the proper use of PPE.

Responding to these COVID-19 complaints, a spokeswoman for the South Shore facility said, “Symphony staff are continually educated on the appropriate use of PPE and the facility monitors this important protocol on an ongoing basis.”

For Symphony’s part,  according to Medicare, more than ninety-seven percent of staff and ninety-one percent of residents are now fully vaccinated against COVID-19. 

Another repeat harm cited in IDPH reports was lack of fall prevention for residents. From Oct. 2019 to Oct. 2021 there are four incidents in which the facility failed to ensure staff were aware of resident fall prevention interventions and identify fall risk hazards. In a report dated Oct. 5, 2021, a resident fell twice in the facility and sustained a left femoral neck fracture, requiring surgical intervention. The facility was fined $27,200. 

According to the Oct. report, staff were not aware of the necessary measures to prevent this resident’s fall or minimize injuries. In the report, the director of nursing told the IDPH official that they “didn’t know why there was no floor mat” in the resident’s room, which would have provided cushion for the fall. 

After the fall, a CNA picked up the resident prior to a physical assessment, and another CNA responded, “you were not supposed to pick her up. The nurse is coming.” Later the surveyor found the same resident on the floor in the dining room, and asked a CNA about the lack of supervision for this resident. In the report, the CNA responded, “the shift just changed, so nobody’s here.”

The facility said in the report the CNAs and nurse involved received education and counseling on information regarding residents at-risk for falls. 

In response to these complaints, a spokeswoman for the network told the Herald, “the facility filed a plan of correction for the alleged deficiency and was then found to be in compliance with the regulations by state surveyors.”

With the other reports involving falls, IDPH found that the facility failed to identify a fall risk hazard on the floor in a hallway, failed to supervise a resident at risk for falls to reduce incidents, affecting two residents who had several falls, and failed to follow their fall policy, resulting in a resident’s fall care plan not being updated.

In a severe case from an IDPH report dating June 8, 2021, a seventy-two-year-old resident fell out of a third story window to the ground and sustained multiple fractures to the left leg, pelvis and back. The resident was taken to the hospital and underwent two procedures to stop internal bleeding. According to the report, the incident was due to the facility’s failure to ensure that windows in residents’ rooms were secured shut.

“I saw (the resident) lying on the ground on her left side on top of the screen. She was awake and alert and oriented. I asked her what happened and ‘Are you ok?” the director of nursing said in the June report. “(The resident) said ‘they were chasing after me.’ I asked who, (the resident) said again ‘the people were chasing after me.’”

In an interview with the attending paramedic, IDPH reports that the paramedic said, “I feel the facility did not provide safety measures to keep this accident from happening.” The facility was fined $25,000.

According to the Symphony South Shore spokeswoman, the facility filed a plan of correction after the incident. Per the plan, a maintenance director is required to check all windows in resident rooms to make sure that they are secured and free from potential accidents. 

A spokeswoman for Symphony South Shore told the Herald, “The facility filed a plan of correction for the alleged deficiency and was then found to be in compliance with the regulations upon revisit by state surveyors.”

The facility also has repeated complaints that stem from a lack of adequate staffing. In a complaint from Nov. 11, 2021, the facility failed to provide the required feeding assistance to a resident. In the report, when inspecting the facility an IDPH official found a resident waiting in their bed with a full tray of untouched food. 

“They have not come to feed me and I am hungry,” said the resident in the November report. “I cannot feed myself.”

A social worker said in the report about twenty minutes later that “(The resident) is supposed to be fed. I am looking for the CNA who is supposed to feed him. I want to know where she is because she did not tell the nurse where she is going. We have staffing challenges today because staff called off.”

An LPN said that same day that they’re “so busy trying to do nursing and CNA work.”

And a CNA stated in the report that the home is understaffed and that she “feeds one resident at a time” and “keeps going.” She said the Director of Nurses knows about staffing issues.

Complaints of staffing shortages came up earlier in an Aug. 13, 2021 report, when a CNA said that they were handling an excessive workload. The CNA said staff are not supposed to have more than thirteen patients to care for per their contract with the facility, but at the time she was assigned twenty-one patients to care for.

CNAs and other facility staff, such as janitors, aides and receptionists, are represented by the Service Employees International Union of Illinois and Indiana. Symphony South Shore is a member of the Illinois Association of Healthcare Facilities (IAHF). 

“Every day we work short,” said one CNA in the report, noting that the understaffing broke their union contract. Per the 2020-2022 SEIU contract with the IAHF, which cites Illinois state law-mandated staffing ratios for long-term care facilities, “The minimum staffing ratios shall be 3.8 hours of nursing and personal care each day for a resident needing skilled care and 2.5 hours of nursing and personal care each day for a resident needing intermediate care.”

When asked about staffing shortages, the spokeswoman for Symphony South Shore noted the facility’s robust recruitment plan. She said the facility has offered bonuses, overtime and pay increases to recruit and retain staff in a market that is extremely short of workers. They also have an employee retention program aimed at appreciating frontline health care workers during these difficult times. In addition, Symphony partners with CNA schools to bring more CNAs into health care and specifically to Symphony South Shore.

According to current Medicare data, however, Symphony South Shore staffing still routinely falls far below state and national averages, and is rated one out of five stars in the category of staffing. There are an average of 178 residents in the home per day. Per Medicare data, which divides the daily number of staff working hours by the number of residents, the average amount of time Registered Nurses have per resident is about sixteen minutes, compared to national and state averages of more than forty minutes. 

The total number of hours both Registered Nurses and direct care staff have per resident is about two hours and twenty-three minutes, compared to a state average of three hours and sixteen minutes.

Nursing homes were difficult places to work long before the pandemic. A March 2022 study from the University of California-Los Angeles found that, from 2017-2018, the median annual turnover rate for nearly all U.S. nursing homes was ninety-four percent. In a June 2022 investigation from AARP, the organization found that from mid-December 2021 to mid-January of this year, almost forty percent of nursing homes nationwide reported short-staffing.

In the AARP report, Emily Paulen writes of the industry’s chronic staffing issues: “That’s largely because certified nursing assistants (CNAs), who make up the largest group of nursing home employees, are among the lowest-paid workers in the health care industry, with a median annual income of roughly $30,000.”

At Symphony South Shore, CNAs and other staff (not nurses) make between $15 and $17 per hour, according to the union. Per the MIT living wage calculator, a living wage in Cook County for a single adult with no children is $19 per hour. 

As expected, when health care staff leave en masse, conditions in homes deteriorate (as does the health of remaining workers). 

Because Chiesa Lucas does not have power of attorney, which would allow her the legal ability to make medical decisions for her mother, she said she can only advocate for her mother to try and improve the conditions while she’s here.

“It’s very difficult for me because I can’t do anything about her being there,” Lucas said. “Because if it was up to me, she wouldn’t be there at all.”

Blair Paddock is a contributing writer for the Hyde Park Herald.