Alden Village North cares for about 90 people, primarily children and young adults, with severe developmental disabilities. The five deaths detailed in Equip for Equality's report involved residents who were 14, 18, 32, 36 and 48 years old.
"We have vulnerable people in a for-profit system where the owners are being basically told, 'You tell us if you think this case warrants us investigating it because you've committed abuse or neglect,'" she said.
Equip for Equality asked the Illinois Department of Public Health to investigate all deaths at Alden Village North since 2008. A department spokeswoman said she could not confirm targets of future investigations but said the agency looks into all credible allegations of neglect associated with a death in a nursing facility.
In its report, Equip for Equality cites the 2009 death of a 14-year-old girl as an example of poor care. The teenager breathed with the aid of a ventilator, and her death certificate states she died of pneumonia.
But the report calls into question a series of decisions prior to her death.
Six weeks before she died, a lab report showed she had "heavy growth" of the bacteria Pseudomonas aeruginosa. The results were relayed to her doctor, but records do not show the teen was started on an antibiotic.
A week later, after a chest X-ray showed pneumonia, the doctor ordered that the girl be given Cipro and Zosyn, even though "the lab report specifically stated that Pseudomonas is resistant to both Cipro and Zosyn," according to Equip for Equality's report.
When the girl was hospitalized, a lab test again found Pseudomonas. This time, physicians placed her on Amikacin, and she became stable and returned to Alden. She was to remain on Amikacin for three more days.
But an Alden nurse recorded in her notes that the pharmacy called to say Amikacin was not available. Equip for Equality investigators found no records that the teen received any appropriate antibiotic for the next two days until she was started back on Amikacin.
A few days later, lab tests showed she still had a heavy growth of Pseudomonas. The results were again relayed to her doctor, but the physician did not order an antibiotic for two days. Three days after the order, the teen died.
"Alden's internal investigation of this matter made no mention of the failed and interrupted treatment of the bacterial infection that likely ultimately led to her death," Equip for Equality's report states. "The facility's failure to adequately treat this infection was significant and should have been noted and investigated further."
Alden's spokesman said the girl was seriously ill and died of natural causes. "We did all that we could for (her) and we were devastated by her loss," he wrote.