Springfield Nursing Home & Bed Sore

Springfield Bed Sore Lawyers Prosecuting Nursing Home Negligence Cases Springfield Bed Sore

Many nursing home residents become victims of neglect or mistreatment at the hands of their caregivers who provide unacceptable levels of care. While signs of physical, emotional and mental abuse often leave obvious clues that something is going wrong, the signs and symptoms of neglect are not always conspicuous. In recent years, our Springfield nursing home neglect attorneys have seen a significant rise in cases involving severe injury and death as the result of avoidable and preventable pressure sores (bedsores; pressure ulcers; decubitus ulcers).

Bedsores typically develop on the resident is unable to reposition or turn themselves over an extended period of time. The lack of mobility and pressure on certain body parts cause a restriction of blood flow to bony areas including the back of the head, shoulders, shoulder blades, elbows, hands, hip bones, sacrum, heels, ankles and toes. Without proper treatment, a newly acquired bedsore can easily become infected and degrade to a level that places the life of the nursing home resident in grave danger.

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Springfield Nursing Home Resident Safety Concerns

The nursing home administrator, medical director and nursing supervisors have a legal obligation to provide proper training to ensure that the entire nursing staff cares for elderly individuals that require additional attention. This includes ensuring that the nursing team is able to:

  • Examine the resident for any sign or indicator of a developing bedsore
  • Ensure that the nursing staff provides proper treatment to prevent a bedsore from developing or heal any existing pressure sore
  • Provide scheduled turning and repositioning of bed ridden and wheelchair-bound residents on a routine basis
  • Help residents who require assistance when transferring from the chair to bed or chair to toilet

Any failure of the nursing home to fulfill their obligation can have catastrophic results. In addition, the nursing facilities ensure that the resident is fully hydrated and eats a well-balanced, nutritional diet to maximize their immune system and decrease their potential for developing a pressure sore.

The Springfield nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC have provided legal representation to many victims of nursing home abuse and neglect. Our dedicated law firm continuously updates our reviews of nursing homes statewide who have been penalized, cited or investigated for complaints and deficiencies involving neglect and abuse. We gather this information from various national databases including Medicare.gov and post our results below. Many families use this valuable information as an effective tool to make the best informed decision when placing a loved one in the care of professional nursing staff.

Comparing Springfield Illinois Nursing Facilities

Our Illinois elder abuse attorneys have detailed the facilities listed below and outlined our primary concerns involving the development, diagnosis and treatment of bedsores. These Pekin, Springfield, Sullivan, Decatur and Hillsboro nursing homes currently maintain a one star out of five possible stars due to issues involving facility-acquired pressure ulcers and the direct harm and caused residents.

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Capitol Healthcare and Rehab Center

555 West Carpenter
Springfield, IL 62702
(217) 525-1880
A “For-Profit” 251-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
1 Star Rating

Primary Concerns –

Failure to Ensure Residents Receive Proper Treatment to Prevent New Bedsores or Heal Existing Pressure Sores

In a summary statement of deficiencies dated 04/20/2015, a complaint investigation against the facility was opened for its failure to “ensure residents with pressure ulcers receive timely necessary monitoring and treatment to prevent infections.” This deficient practice affected to residents at the facility “reviewed for infected Pressure Ulcers.”

A complaint investigation was initiated after a review of nurses notes documented on 04/01/2015 where a “Certified Nurses’ Aide (CNA) alerted the writer that a resident has an open area two centimeters (CM) by 1.5 CM [on the spine]. No drainage noted. Wound team alerted and family made aware. This nurses note was signed by [a LPN (Licensed Practical Nurse)].” However, “there is no documentation regarding the open area on [the resident’s] spine in [the resident’s] current physician’s orders or on the April 2015 Treatment Administration Record (TAR).” In addition, “there is no further documentation regarding the open area on [the resident’s] spine in [the resident’s] Nurses Notes.”

The state investigator conducted in 04/13/2015 12:56 PM interview with the facility’s Wound Nurse who indicated “that no one ever told her about the open area on [the resident’s] spine [… and] that there is no record of [the resident’s] physician being notified of the area and the treatment order was not obtained.” At 1:08 PM, a different LPN stated “that she said something in passing about a new area on [the resident’s] spine to [the first LPN, but] said that [the first LPN] has a lot of responsibility, so [the first LPN] probably forgot.”

The state surveyor conducted a telephone interview on 04/15/2015 at 2 PM with the resident’s Physician’s Assistant who reviewed the resident’s clinical record and spoke on behalf of the resident’s physician saying “that the facility did not notify [the resident’s physician] regarding a pressure sore on [the resident’s] spine.

Our Springfield Illinois nursing home abuse attorneys recognize that any failure to follow protocol when providing treatment for residents suffering with bedsores might place the resident’s life in Immediate Jeopardy. The deficient practice might be considered negligence or mistreatment because it does not follow the established procedures, policies and protocols adopted by Capitol Health Care and Rehabilitation Center and violate state and federal nursing home regulations.

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Timbercreek Rehabilitation and Health Care Center

2220 State Street
Pekin, IL 61554
(309) 347-1110
A “For-Profit” 202-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
1 Star Rating

Primary Concerns –

Failure to Follow Protocols for Treating Pressure Ulcers that Resulted in a Degrading Wound

In a summary statement of deficiencies dated 11/05/2015, a complaint investigation was opened against the facility for its failure to “provide wound care for [a resident] reviewed for pressure ulcers.” This deficient practice affected one resident at the facility.

The complaint investigation was initiated in part after record reviews, interviews and observations involving a resident who stated on 11/05/2015 at 10:50 AM that “about a week ago I waited for over 40 minutes to get taken off the bedpan and the sore my bottom became wide open again. It was extremely painful and I was in tears.”

The state investigator reviewed The 10/12/2015 Resident’s Nursing Admission Assessment and noted it “does not document that [the resident] had any skin issues on his bottom area” meaning that any skin issues in that area were acquired at the facility after admission.

The state surveyor conducted a 11/05/2015 11:40 AM interview with The Facility’s LPN (Licensed Practical Nurse) who stated that he/she “makes rounds with the wound specialist weekly [… and] on 10/27/2015, [the resident] asked the wound specialist to look at his bottom. That is when we found the wound to his right posterior upper thigh/lower buttocks area and started treatment order. [The resident] told me it is from being on the bedpan which could be possible.”

An observation of the resident’s wound on 11/05/2015 at 12:15 PM indicated that the resident “had a draining, red open wound approximately 5.3 centimeters by 5.7 centimeters by 0.1 centimeters deep to his right posterior upper thigh/lower buttock area.

The state surveyor then reviewed the resident’s 10/27/2015 TAR (Treatment Administration Record) documenting physician’s orders. “The same form documents the treatment was not signed out as completed on 10/27/2015, and 10/29/2015 through 10/31/2015”. The resident’s TAR dated 11/01/2015 through 11/30/2015 does not document any wound treatment signed out as completed from 11/01/2015 to the current date of 11/05/2015.”

The facility’s physician assistant wound specialist stated on 11/05/2015 that “yes it is possible for [the resident’s] wound to his right posterior upper to have been caused by being on a bedpan too long.”

Our Pekin nursing home neglect attorneys recognize that any failure by the nursing staff and administration to follow procedures when providing treatments to patients with bedsores might be considered neglect or mistreatment. In addition, the deficient protocol fails to follow established protocols adopted by Timbercreek Rehabilitation and Health Care Center.

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Eastview Terrace

100 Eastview Place
Sullivan, IL 61951
(217) 728-7367
A “For-Profit” 63-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
1 Star Rating

Primary Concerns –

Failure to Ensure Residents Receive Proper Treatment to Prevent New Bedsores or Heal Existing Pressure Sores Using Methods to Avoid Cross-Contamination

In a summary statement of deficiencies dated 07/15/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “utilize correct technique for pressure sore treatment to prevent cross-contamination for [a resident at the facility] reviewed for pressure sores.”

The deficient practice was noted after review of 06/15/2015 dietary notes at the facility that documented a resident “has stage II pressure ulcers, one on [the resident’s] right buttock measures 0.1 centimeters by 0.1 centimeters in the left buttock measuring 0.1 centimeters by 0.1 centimeters on the resident’s right and left buttocks.

The state surveyor noted a member of the nursing staff “cleaned [the resident’s] right buttock with gauze, then the same contaminated gauze proceeded to clean [the resident’s] right side peri-wound, the left buttock wound, and the left buttock peri-wound. Without washing hands or changing gloves, [the member of the nursing staff] then cut in place the clean dressing on the right buttock then the left buttock wounds.

In a 06/13/2015 3:40 PM interview, the nursing staff member stated “she messed up and touch clean areas with contaminated gloves [… and] she should have washed hands and change gloves after cleaning [the resident] wound.”

Our Sullivan Illinois nursing home neglect attorneys recognize and any failure to follow protocols when providing treatment to residents suffering with pressure sores could place their health and well-being in jeopardy. The deficient practice might also be considered negligence or mistreatment because it does not follow established protocols adopted by Eastview Terrace and violates state and federal nursing home regulations.

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Heartland of Decatur

444 West Harrison Street
Decatur, IL 62526
(217) 877-7333
A “For-Profit” 117-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
1 Star Rating

Primary Concerns –

Failure to Ensure Residents Receive Proper Treatment to Prevent New Bedsores or Heal Existing Pressure Sores

In a summary statement of deficiencies dated 11/20/2015, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “assess a pressure ulcer, evaluate the treatment to document the pressure ulcer management on [one resident at the facility] reviewed for pressure ulcers.”

The deficient practice was noted at the root review of a resident’s records, observations and interviews with nursing staff concerning a resident with pressure ulcers. The resident’s 08/24/2015 in 09/13/2015 Braden Scale used as an effective tool to predict pressure ulcers documents that the resident “is high risk for pressure ulcers and has a history of pressure ulcers. The progress notes dated 10/13/2015 document that an open area on [the resident’s] left buttock is noted and identified at this time.” A facility 10/13/2015 facsimile transmitted to the primary care physician “documents a treatment order to the open area on [the resident’s] left buttock and a wound consult. There are no measurements, assessments or descriptive details of the wound documented in [the resident’s] medical records until 13 days later.”

A 10/26/2015 report titled Wound Care Specialist Evaluation documents a change in measurements that are “documented as 1.0 centimeters by 0.7 centimeters with a depth of 0.4 centimeters. The same report documents another pressure ulcer identified as unstageable (due to necrosis) of the coccyx measuring 1.5 centimeters by 1.5 centimeters with undeterminable depth.”

The state surveyor conducted in 11/20/2015 9:40 AM interview with the primary care physician who stated “that the expectation of the wound consult order would be that the [resident] be seen on the next weekly visit (10/19/2015). [The primary care physician] stated in the 13 date your term from notification and [the resident] being seen by the Wound Specialist, [the primary care physician] expected that the wound in the treatment should have been evaluated [… but] stated there was no notification of the wound worsening and if there had been, the treatment could have been changed.”

Our Decatur nursing home neglect attorneys recognize that any failure to follow established protocols when treating residents suffering pressure sores might be considered negligence or mistreatment if the deficient practice causes additional harm to the resident. The facility failed to follow the facility’s policy that directs staff on expected protocols in providing care and treatment to residents with bedsores. The policy reads in part:

“If a pressure ulcer is identified, a Pressure Ulcer Scale for Healing (PUSH Tool) is initiated by a member of the wound team for each site identified. A comprehensive evaluation is completed and documented in the patient’s clinical record and may include, but is not limited to: location, depth, appearance of surrounding skin, presence and location of tunneling, presence and location of undermining, evidence of infection and pain.

Daily skin evaluations are completed by the licensed nurse for any patient with a pressure ulcer. Weekly skin evaluations are completed by the licensed nurse for any other patient. Skin evaluations are documented in the clinical record. The PUSH Tool allows you to graph scores over time for each ulcer. The graph provides a visual indicator of healing. Any increase in the PUSH Tool score requires a more complete evaluation of the ulcer.”

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Hillsboro Rehabilitation and Health Care Center

1300 East Tremont Street
Hillsboro, IL 62049
(217) 532-6191
A “For-Profit” 121-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
1 Star Rating

Primary Concerns –

Failure to Ensure Residents Receive Proper Treatment to Prevent New Bedsores or Heal Existing Pressure Sores

In a summary statement of deficiencies dated 07/14/2015, a notation was made by a state surveyor during an annual licensure and certification survey involving the facility’s failure to “provide timely turning and repositioning, pressure sore identification, monitoring and treatment for [5 residents at the facility] reviewed for pressure sores.”

The state surveyor conducted an interview with the resident at the facility on 07/07/2015 at 1:55 PM where the resident indicated “she did not have a pressure sore prior to admission to the facility and that she developed her pressure sore in the facility [and] also stated she needed staff assistance for care.”

A review of the Hillsboro Rehabilitation and Health Care Center 03/05/2015 Weekly Pressure Ulcer Report documents the resident “developed a facility-acquired unstageable coccyx pressure sore measuring 3.0 centimeters by 3.4 centimeters by <0.5 centimeters which was identified on 03/05/2015.” A review of the resident’s revised June 2015 care plan “documented she was referred to an outside wound clinic that debrided her pressure sore and placed her on a [redacted medical device].”

The resident’s MDS (Minimum Data Set) Documents of the Resident “Has Moderate Cognitive Impairment, requires total dependence on two-person assistance for transfers, toileting and bathing, extensive assistance with two people physical assistance in bed mobility, dressing and personal hygiene.”

A review of the resident’s revised text 2/3/2015 care plan documents that the resident “has the potential for pressure ulcer development related to requiring assist for transfers and mobility and incontinence [and] is to have a weekly skin checked by a licensed nurse and assistance to reposition and turn every two hours and PRN (as needed).”

The state surveyor observed the resident on 07/08/2015 while “in her wheelchair with no repositioning from 8:52 AM until 11:13 AM based on 15 minutes or less observation intervals.” In addition, the resident was transferred out of the room at 8:52 AM and was not taken to the toilet until 11:13 AM without any assistance or repositioning within that timeframe.

Our Hillsboro nursing home neglect attorneys recognize it any failure to follow procedures and protocols when providing treatment, assistance and repositioning for resident suffering bedsores might be considered negligence or neglect. In addition, the deficient practice directly violates federal and state nursing home regulations and does not follow the established policies adopted by Hillsborough Rehabilitation and Health Care Center including their 02/02/2014 policy titled. Prevention of Pressure Ulcers Policy and Procedure that reads in part:

“The facility should have a system/procedure to ensure assessments are timely and appropriate and changes in condition to be recognized, evaluated, reported to the practitioner, physician, and family and addressed.”

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Mason Point

One Masonic Way
Sullivan, IL 61951
(217) 728-4394
A “For-Profit” 122-certified bed Medicaid/Medicare-participating facility
Overall Rating – 1 out of 5 possible stars
1 Star Rating

Primary Concerns –

Failure to Ensure Residents Receive Proper Treatment to Prevent New Bedsores or Heal Existing Pressure Sores

In a summary statement of deficiencies dated 03/26/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “notify the physician of a dietary recommendation to promote wound healing” and the facility’s failure “to implement pressure relieving devices for [a resident] reviewed for pressure sores.”

The deficient practice was noted upon reviews, observations and interviews including a resident’s 02/11/2015 Newly Acquired Skin Conditions Form documenting that the resident “has a facility acquired, stage II pressure sore to her left heel.” The Follow-Up Newly Acquired Skin Conditions Form dated 02/18/2015 documents that the resident “has a facility acquired stage II pressure sore behind her left ear.”

The resident’s 02/20/2015 Dietary Note documents that “she [the resident] may benefit from supplementation for healing. She is on a 200,000 cc fluid restriction. Will recommend one scoop protein powder BID (twice a day). A Request for Diet Change Form dated 02/20/2015 four [the resident] documents [the Registered Dietitian] recommendation to add one scoop protein powder BID for wound healing and skin integrity.”

However, in an interview conducted on 03/24/2015 at 1:30 PM went the facility’s Director of Nursing confirmed that she “was unsure how it (dietary recommendation) was missed.” The Director of Nursing confirmed that the Registered Dietitian will email her recommendations and then the recommendations are faxed of the physician for approval. [The Director of Nursing] stated that the dietary recommendation was not faxed to the physician.”

A review of the facility’s 02/17/2015, 03/10/2015 and 03/20/2015 Wound Tracking Report documents and assessment and wound measurements for [the resident’s] pressure sores to her left ankle and behind her left ear. [The resident’s] Nursing Notes dated 2/2015 through 3/2015 and [the resident’s] Treatment Administration Record [TAR] for 2/2015 and 3/2015 do not document an assessment or measurements of [the resident’s] pressure sores.

The treatment nurse stated during a 03/25/2015 11 AM interview that “she is responsible for measuring wounds and responsible for weekly assessment of the facility’s wounds. [The treatment nurse] stated that she tries to measure weekly but is sometimes pulled to work the floor and is unable to get the measuring and assessment of the facility’s wounds completed every week.”

A CNA (Certified Nursing Assistant) confirmed on 03/23/2015 that the resident’s “heels were not floated [and] she floats [the resident’s] heels when she is in bed but not so much in the recliner [… and] that after lunch she transferred [the resident] into a recliner but did not float her heels [… and] stated that she should have placed a pillow under [the resident’s] legs to float her heels.

Additionally, observations on 03/23/2014 at 1:20 PM indicated that the “resident’s glasses did not have padding to cover the ear piece.”

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Our Sullivan nursing home neglect attorneys recognize that any failure to follow protocols when providing treatment and care to residents suffering pressure ulcers could cause additional harm. The deficient practices of providing insufficient care might be considered negligence or mistreatment because it does not follow establish procedures and protocols adopted by Mason Point and violates federal and state nursing home regulations.

Justice for Springfield Nursing Home Victims Suffering Facility Acquired Sores

In spite of what administrators, medical directors and nursing staff tell you and the other members of your family, acquiring a bedsore is not a normal part of growing old. Even a simple pressure sore can advance to a life-threatening stage without proper, effective and quick treatment. Typically, these progressive pressure sores indicate that some form of mistreatment or neglect is occurring in the nursing facility. Without highly effective treatments, a small reddened area anywhere on your loved one’s body can become an extremely painful condition in its advancing stages, especially if the degradation of the sore leads to a life-threatening infection.

The laws of Illinois on elder care are strict and provide protection for residents in nursing facilities to ensure they are not neglected or abused. If your loved one has acquired a bedsore while residing in a nursing facility, the Springfield nursing home abuse attorneys at Rosenfeld Injury Lawyers LLC can intervene on your behalf to stop the mistreatment now. Our Illinois team of dedicated knowledgeable attorneys has years of experience handling cases involving pressure ulcers occurring while the individual was a resident in a nursing home.

We encourage you to contact our Springfield elder abuse law offices by calling (800) 926-7565 today to schedule your free, full case evaluation. We provide viable legal representation to ensure that the facility that caused your loved one harm remains legally and financially accountable for all the expenses of medical intervention your family has endured. We accept nursing home abuse and neglect cases through contingency fee agreements. This means you are provided immediate legal representation without paying us any retainer or upfront fee. Our fees are paid only after we negotiate your acceptable out of court settlement or when we win your case at trial, if necessary. All information you share with us will remain confidential.

Should you have questions about Illinois law related to pressure sores, view our page here.

For information on bed sores and nursing home negligence in other Illinois cities, please review the pages below:

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Client Reviews
★★★★★
Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa
★★★★★
After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric