Compromised Care: West Side nursing home probed after death

State authorities are investigating a West Side nursing home following reports of violence that include the August beating death of a 72-year-old dementia patient, allegedly by a psychotic felon also living in the facility, records obtained by the Tribune show.

Ardyce Nauden, 62, who has a history of drug convictions and aggressive behavior, was charged with attempted first-degree murder and aggravated battery of a senior citizen, but the older man died a month later, and prosecutors are now reviewing whether to upgrade the charges.

Nauden told authorities that he repeatedly punched Andres Cardona in the head because Cardona wandered into his room and began eating Nauden's lunch of pot roast, green beans and potatoes.

The alleged beating at the Columbus Park Nursing & Rehabilitation Center, 901 S. Austin Blvd., is emblematic of the volatile mix at some Illinois nursing homes. More than any other state, Illinois relies on nursing facilities to house felons and younger mentally ill adults, often housing them with the elderly and disabled.

The Illinois Department of Public Health does not track the number of homicides and other reports of violence in the facilities, but Cardona's case is one of three known resident deaths investigated as potential homicides in the state during the last 18 months.

Details of the attack underscore the lack of data-sharing among police, facilities and health authorities about reports of assault and abuse.

When the Tribune last month asked the state health department for all records of assault allegations at Columbus Park during the previous 90 days, health officials initially said they had none.

But when pressed, the department this week located records on the Cardona beating and two other recent alleged batteries -- even though Chicago police reported 11 alleged batteries inside the facility during those 90 days.

On Tuesday, state health authorities opened a broad investigation to determine whether Columbus Park accurately reported incidents of patient violence and abuse, including the Nauden case. Health department spokeswoman Melaney Arnold said the investigation was prompted by the Tribune's inquiries, adding that the department is inundated with facility incident reports, and "unfortunately with the staffing that we have, we're not always able to connect the dots."

Tribune reporting has "brought to light something that the department has been dealing with for a long time," she said. "It is not a perfect system."

Alleged stabbings, rapes and assaults inside state nursing homes were highlighted in a recent Tribune series that have led Gov. Pat Quinn and state lawmakers to seek legislative and policy solutions to the violence and the shoddy care of mentally ill people in some facilities.

Columbus Park employees had documented Nauden's history of "violent, aggressive behaviors," but the facility failed to protect Cardona and other residents, a state health department investigation determined.

Columbus Park spokesman Ron Nunziato denied that Nauden previously had been physically aggressive at Columbus Park and said the facility is formally challenging the state's findings that Columbus Park failed to safeguard others from Nauden.

He cautioned that some police reports about Columbus Park concern alleged batteries that did not actually result in "substantiated harm" or involved staff and not residents, and thus did not have to be reported to state health authorities.

"Columbus Park provides quality health care, (and) staff take every opportunity to ensure that residents are safe," Nunziato said. "There are sometimes incidents beyond our control."

Cardona's death, he added, "was an unfortunate, difficult situation."

Nauden has pleaded not guilty and is being held in Cermak Hospital at Cook County Jail. He could not be reached for comment.

Columbus Park is part-owned by longtime nursing home executives Bryan Barrish and Michael Giannini. They and their companies have an ownership stake or consulting role in 13 Illinois facilities that house nearly 6 percent of the felons and 10 percent of the 14,258 mentally ill nursing home patients in the state.

Located just south of the Eisenhower Expressway, the five-story home was recently given the lowest overall-quality rating of "well below average" by federal regulators.

Roughly a quarter of the 186-patient facility's residents have a primary diagnosis of mental illness, just under half are younger than 65 and 32 are convicted felons, according to the most current state records.

Only one other Chicago nursing home had more reports of assault, battery or sexual assault inside the facility during the 17-month period from March 2008 to August 2009, according to preliminary Chicago police data. Columbus Park had 28 such reports.

A week after Nauden allegedly beat Cardona, facility employees found a female resident with bruises on her face after being punched by a 53-year-old who suffered from "auditory hallucinations and delusions," a state report said. The alleged assailant had hit others before, but Columbus Park didn't address her "negative acting out behavior." Nunziato said the facility is challenging that finding.

Nauden was admitted to Columbus Park in mid-July; he spent much of his time in his wheelchair, chain-smoking cigarettes while hooked up to an oxygen tank.

He clashed frequently with peers and staff and, in separate incidents, slammed his oxygen tank on the floor and tossed his breakfast plate while yelling vulgarities, state investigators found.

Under Illinois law, background checks on all new residents are limited to in-state convictions, and Nunziato said Columbus Park did not learn that Nauden was twice imprisoned for felony convictions -- for cocaine possession in Nebraska and crack-selling in Arkansas -- and had several other arrests, including two in-state battery charges that were dropped.

Living near Nauden in Room 325, Cardona wandered the halls of Columbus Park with a confused look on his face, absently "picking up things on the unit that did not belong to him," the state report said. Diagnosed with schizoaffective disorder and dementia, Cardona would put items in his underpants and "just walk up and down the unit but would not harm anyone."

Around 2 p.m. Aug. 21, Nauden awoke in his room to find Cardona eating off his lunch tray. Nauden tossed a glass of water at Cardona, then pulled him closer to his bed and began punching his face. He wore three heavy rings.

"I ... beat his ass," Nauden later told a nurse's aide.

Cardona slumped into his wheelchair, unconscious and " bleeding profusely" from one eye, the state report said. He went into cardiac arrest and stopped breathing.

Rushed to Mount Sinai Hospital, Cardona was put on a ventilator but remained "unresponsive, flaccid, and died ... weeks later from the effects of his assault," the state report said.

Columbus Park faxed a required incident report to state health authorities five hours after the attack. The single-page report said Nauden told staff that he " 'threw a cup of water at [Cardona] and hit him in his eye' then pulled the call light." A nurse "noted blood near [Cardona's] eye and called 911," the facility's report said.

State health authorities told the Tribune that the facility report failed to convey the severity of Cardona's injuries, and so the short-staffed agency did not immediately investigate. It was not until the alleged assault involving the 53-year-old took place a week later that inspectors moved in to review the second case and began examining the Cardona attack.

Nunziato said the facility provided the best information it had on Cardona within the required 24 hours.

When prosecutors learned of Cardona's death in early October, they contacted the Cook County medical examiner's office, which is reviewing his medical files as part of its death investigation.

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