Abuse and neglect claims, investigations rampant in local group homes

ROCKFORD, Ill. (WIFR) - “She had a very creative mind. She loved to draw, she loved music. Her favorite artist was Michael Jackson,” says Rebecca Ruiz, describing her late sister Ivette. The bittersweet memories of Ivette are vivid for Rebecca, almost 13 years after her sister’s death.

“She wanted to learn how to read, even though they told her she couldn’t, so I taught her little by little and she was up to a second grade level,” she adds.

Ivette died in 2010 after a fall at Willowglen Academy in Freeport. The home is now under the name Broadstep. It’s a facility that provides services and lodging to those with developmental disabilities, like Ivette. She lived at the community integrated living arrangement, or CILA, for a few years and struggled with mobility issues for weeks before the final fall that killed her.

“She had to go to the washroom, but they let her go to the washroom by herself, and she fell,” remembers Rebecca. “They didn’t give her medical assessment right away. She was taken to the group home later that day, where she fell again.”

Rebecca says it wasn’t until Ivette was in the hospital with irreversible brain damage that Willowglen gave her family the full story.

“My first reaction was shock,” she says. “They didn’t tell us she had fallen earlier in the day. I think the only reason they called us is because she was in a coma.”

In Illinois, CILA homes are defined by the department of human services as “a living arrangement for adults in a group home, family home or apartment where eight or fewer unrelated adults with developmental disabilities live under supervision of the community developmental services agency.”

Tara Devine, the Ruiz family’s attorney, says Rebbeca and her mother sued to try to motivate change at Willowglen.

“It was very important for Rebecca and her to follow through on this because they don’t want this to happen to another family,” explains Devine.

Within the past few years alone, the Illinois Inspector General (OIG) has investigated hundreds and substantiated dozens of abuse and neglect claims in Stateline CILA homes.

In one, a Willowglen employee was investigated for reportedly putting a resident in a headlock and grabbing them by the neck. Later that year, the same employee allegedly let a resident take a scalding hot shower which resulted in severe burns on 45 percent of the person’s body, third degree burns on over 15 percent.

At Goldie Floberg in Rockton, a 2020 investigation found an employee kicked a resident, dragged them across the floor and pinned them against the wall. That worker was fired and the information turned over to police.

In Dixon at Kreider Services in 2022, a resident was left outside in the sun for so long, he had a seizure, fell, and hit his head. He also developed heat stroke and a second-degree burn.

Other confirmed reports from CILAs in the area include patients being given the wrong medication and having adverse reactions, patients wandering away in extreme heat or extreme cold. Other reports find employees verbally abusing patients or leaving unannounced for extended periods of time during their shifts..

While many residents walk away and heal from these events, others like Ivette Ruiz or Jeffrey Davin, aren’t so lucky.

Steve Levin is Davin’s family’s attorney. They are suing Milestone in Rockford after an incident in early 2020. Over a period of five months, Milestone employees struggled to place Davin’s catheter on multiple occasions. Eventually, Davin suffered urethral perforation and sepsis. The final procedure, according to a physician consulted by the prosecution, contributed to his death.

“How any nurse could possibly do what they did in the case of Jeffrey Davin is mind-boggling to me,” says Levin.

He says a combination of short-staffing and spotty regulation led to the deaths and a staggering number of other CILA abuse and neglect cases.

“It’s scary to me as more as we focus more attention these type of issues, what might be out there,” he adds. “You don’t go into a hospital and they say to you, you know, we could have done this operation a little better, but we just are having some huge staffing problems. In the institutional care setting, they often, in essence, say that.”

“You have underpaid, undertrained staff that are providing the majority of the care to a very vulnerable population,” adds Devine.

Ruiz and Devine both say lack of staffing was Willowglen’s defense after Ivette’s death.

“They said they cared for her more than we did. They had the legal amount of people there for care, but it was too much for the staff,” Rebecca remembers.

Rebecca and her mom were awarded a record-setting $1.6 million in their wrongful death lawsuit against Willowglen.

Rebecca explains, “My sister was priceless, so no amount of money would ever be weighed against her. Part of me did this because I wanted them to feel the hit of pain I was feeling.”

And though the verdict in favor of Ivette’s family came down more than seven years ago, the issue is still understated and ever-present around the state and Stateline.

“Can you blame the staff, can you blame the corporation? It’s a system failure at the end of the day,” says Devine.

Broadstep, which took over Willowglen in 2019, issued the following statement when asked for comment:

“We empathize with the family of Ivette Ruiz on her passing in 2010. Since 2019, Willowglen has operated under new management with a renewed focus on providing quality care to our residents. We continue to work closely with DHS to ensure that our staffing and care practices meet regulatory standards.”

Broadstep has not had any substantiated claims of abuse as of April 5 of this year, according to the Illinois Department of Human Services.

23 WIFR reached out to the other CILA homes mentioned in these reports or other lawsuits. Each declined to comment, except for Kreider Services in Dixon. The CILA will comment on the issue in part two of this series.

Also in part two, 23 WIFR will speak to local lawmakers about potential legislation to further regulate CILAs in the state.

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