A nursing home in Morton has received over $20,000 in fines after violating state regulations on three separate occasions in the summer of 2025.
Apostolic Christian Timber Ridge, a member of the LifePoints system that provides care to adults with intellectual and developmental disabilities, received a fine of $20,750 from the Illinois Department of Public Health after it failed to ensure outside supervision for someone who was choked by a resident of another facility; failed to appropriately implement someone’s transfer while neglecting to ensure facility protocol was followed; and failed to ensure medications were provided to three residents last summer.
In the first case, the facility received a fine of $750 after a resident was choked by someone from another facility last July while no one was in their room to supervise.
According to IDPH’s report, the resident had severe intellectual disabilities and needed 24-hour supervision. On July 22, 2025, a staff member found a resident from another facility with their hands around the resident’s neck in their room. No staff members were inside, as one had been taking another to the facility’s bus loading area and others were busy changing another resident.
A direct support employee told IDPH that their colleague was outside the room while they were taking another resident to the bathroom. The resident had been sitting on the couch with the visitor sitting with them. When they returned to the room, the visitor had their hands wrapped around the resident’s throat and was shaking them.
The support employee said that they shouldn’t have went to the bathroom, noting that they always needed to be someone in the resident’s room at all times.
A qualified individual disabilities professional told IDPH that normally, two staff members were in the room with the resident, and that someone else should have been there while the support person had gone to change the other resident.
Another official reiterated the need for 24-hour supervision of the resident to prevent incidents like this.
Second case at Morton nursing home in 2025
In the second case, the facility received a fine of $20,000 after facility protocol had been neglected during a woman’s mechanical transfer in August 2025. According to IDPH’s report, the woman had moderate intellectual disabilities along with spastic hemiplegic cerebral palsy, which affects one side of a person’s body.
She was also non-ambulatory and required the assistance of a mechanical lift to transfer her from place to place.
On Aug. 14, 2025, an aide asked for a nurse to come to the woman’s room to help take her to the bathroom. The woman was transported to the bathroom via ceiling mechanical lift, but while en route, she began bleeding from her rectum.
When the nurse arrived in the room, she saw large drops of blood on the floor, along with a pad under the woman that was soaked in blood. An investigation began into what happened, which revealed that the woman told a direct support person that she needed to go to the bathroom. Using her wheelchair, the direct support person got her back to her room and prepared the sling for a mechanical transfer.
The direct support person removed the woman’s pants, but she began to slip out of the chair as the aide stuck their head out the window and asked for help. She saw another direct support person walking by and enlisted their help. Both noted that the woman had been slipping out of the chair significantly by this point, also saying that the woman would get frantic and bouncy when she needed to go to the bathroom.
When the other direct support person arrived in the room, they noticed that the sling had been attached to the lift and the lift had been raised slightly. They said their co-worker had lifted the sling slightly to ensure the woman wasn’t falling out of the lift, something that the first direct support person ended up confirming.
The direct support person also admitted that the woman had been unbuckled as they asked for help with the lift. However, as the two of them began to raise the sling, they noticed that the entire chair was being lifted, with one of them noting the sling had gotten caught on a foot rest.
The chair would need to be lowered to correct it, and once that was finished, the pair returned to getting the woman into the bathroom. However, as she was being lifted, they saw that blood and stool were leaking down to the floor. An inspection of the woman’s wheelchair showed that there was dried fecal matter on the right foot pedal brake, located immediately off of the right and left ends of the chair edge.
The investigation concluded that the bleeding came from the brake pedal penetrating into the rectum during the transfer, as an incorrect procedure had been used to get the woman into the chair. IDPH said that the aide should have buckled the woman in the chair before seeking help and shouldn’t have raised it at all before finding another person to help.
One week after the incident, the wheelchair was brought into an exam room at the facility, with a pair of metal bars angled up and towards the back of the seat on each side of the chair. A brown substance was seen on the angled right bar and right front of the wheelchair pad. The aide demonstrated how the resident had been transferred and recreated the incident.
Later that day, the aide admitted that she should have kept the woman buckled while she asked for help, according to IDPH records.
A licensed practical nurse told IDPH that on the day of the incident, the other aide had enlisted their help at the request of a registered nurse. When they got into the woman’s room, they found large piles of liquid stool and a good amount of blood leading from the wheelchair to the bed.
The woman had been lying in her bed, with the registered nurse trying to see where the bleeding was coming from. After rolling her over on her left side, they determined that it looked like an external hemorrhoid was the cause. It was determined that she needed to be sent to a hospital.
The woman came to an emergency room complaining of rectal bleeding, along with a laceration of her buttocks and an tear in her sphincter. A procedure was performed to dissect and remove necrotic tissue impacted by the incident.
Both an occupational therapy assistant and a residential service director said that mechanical lift transfers must always have two staff members present to monitor the resident. The residential service director said that the woman could only be moved by mechanical lift transfer and transfer protocols for the woman also identify that she can only be moved by mechanical or ceiling lift.
Third violation at Morton nursing home
In the third case, the facility failed to ensure medications were immediately administered upon preparation for three residents in August 2025, although they were not fined for this violation.
IDPH’s report said that the medications for three residents had been pre-popped – removing them from the containers before being administered to someone – by a licensed practical nurse, who admitted to IDPH that they had done this. They said that this is something they were not allowed to do.
The report said that the medications had been sitting on the top of a counter in the facility’s medication room on the morning of Aug. 21, 2025. One tray had two cups of orange liquid and two additional cups of a crushed powder. The second try had one cup of crushed powder, another cup of orange liquid and a packet of esomeprazole, also known as Nexium. The third tray had one cup of crushed powder with liquid on top and another one with a clear liquid.
The facility’s director of nursing said that it isn’t best practice for someone to pre-pop medications, noting that it was prohibited at the facility.
Blake Stahl, executive director of Apostolic Christian LifePoints, said in a statement to the Journal Star that the facility takes the regulatory process seriously and it has handled the citations with guidance from IDPH. Stahl also said that the facility values the trust that families place in them to provide care to their loved ones, also noting that they value resident safety, dignity and quality of life and use those to guide their actions and response to the citations.
This article originally appeared on Journal Star: Morton nursing home fined over $20,000 for violating state regulations
Reporting by Zach Roth, Peoria Journal Star / Journal Star
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By Zach Roth, Peoria Journal Star | USA TODAY Network
