LAST spring, within the span of a month, four people died at Beverly Farm, a nursing home in Godfrey, Ill. This month, the state health department fined the home $20,000.

All four people, who aren't named in state inspection reports, had developmental disabilities. Three of them died because staff members couldn't find, or didn't have, crucial emergency equipment when it was needed. The fourth died when an ambulance was not called promptly.

When state health inspectors visited Beverly Farm, they found that none of its 10 patient "cottages" had a full complement of emergency equipment. Not that it would have mattered. Several staff members admitted they had no idea what one piece of equipment - a resuscitation device called an Ambu bag - looked like, or how it was used. Yet they had been sent on a frantic, fruitless search for one when a 54-year-old patient stopped breathing the night of April 20. He died.

Four days later, an 86-year-old woman had difficulty breathing. Again, the staff couldn't find an Ambu bag. She died.

The inspectors came across one emergency oxygen tank at Beverly Farm that should have been replaced 16 years earlier. Not that it would have mattered. None of the tanks had regulators, which adjust the flow of oxygen. Several lacked face masks. Nor was there equipment to measure patients' oxygen levels.

The equipment would have come in handy two weeks later, on May 3, when a 77-year-old woman stopped breathing twice. Staff members assigned to monitor the woman's condition didn't know what symptoms to look for; emergency resuscitation equipment was locked in an office. They paged a nurse for an hour before getting help. The woman died.

On May 20, eight hours had passed before an ambulance was called for a 44-year-old man seriously ill with pneumonia. He died.

This was not the first time Beverly Farm was in trouble. In 1998, five patients suffered broken toes on a single day. An aide was later charged with battery, but prosecutors dropped the case because the victims' profound mental retardation made them unable to testify.

Illinois law sets a minimum fine of $10,000 for nursing home violations that result in "death, serious mental or physical harm (or) permanent disability." Beverly Farm was fined just half that because two of the deaths couldn't be linked conclusively to the lack of emergency equipment.

Beverly Farm is appealing the fines, and odds are they will be reduced. Inadequate though they are, more than half of the nursing home fines in Illinois are cut or eliminated on appeal.

A few years ago, nursing home regulators asked the Illinois General Assembly to increase fines for violations. That's just one of several urgently needed changes in state nursing home laws. But legislators there, as in so many other states, refused to strengthen the laws.

It's worth noting that the nursing home industry gave $652,000 to candidates for Illinois state offices in 1999 and 2000. Speaker Michael Madigan, D-Chicago, took $159,100. Gov. George Ryan, a Republican, took $89,650.

It might be possible for the state to ignore the death of one person. In life-or-death situations, mistakes are made. Tragedies happen. Old people die.

But you'd think the deaths of ((ITAL))four people in a month's time at the same nursing home would pique the interest - and prick the conscience - of ((ITAL))someone in Illinois government, just a little.

Who has the courage to face the four ghosts of Beverly Farm? Who has the anger to demand a full accounting for their deaths? Who has the strength to protect the living?