Waukegan Nursing Home Neglect & Bed Sore

Attorneys Prosecuting Waukegan Bed Sore Cases

Many nursing home residents are wheelchair-bound and/or bedridden and lack the capacity to readjust their body position without assistance. If the body left in the same position for too long, the unrelieved pressure on bony prominences like the ankles, hips and sacrum can restrict blood flow circulation and cause damage to the skin and underlying tissue. In fact, the Waukegan nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC have handled many cases where nursing home residents have suffered a decline in their health due to life-threatening bedsores.

A bedsore (pressure sores; pressure ulcers; decubitus ulcer) can begin to develop in as little as two hours if blood flow is restricted to the area. If the sore is not detected, identified or treated, a small barely-detectable pressure sore can degrade to a serious open wound that is highly susceptible to sepsis (blood infection), osteomyelitis (bone infection), gangrene and eventually death.

Developing a facility-acquired bedsore in a nursing facility has become a serious problem throughout Lake County. In many cases, residents develop pressure sores due to a lack of monitoring by unskilled staff, overcrowded conditions with minimal staff members or outright neglect. Our Waukegan elder abuse lawyers believe that the number of civil cases involving debilitating pressure sores is likely to escalate in the Chicago metropolitan area in the years ahead. This is because the aging population is increasing at an alarming rate as many more individuals enter their retirement years.

More than 88,000 residents live within the Waukegan city limits and millions more all throughout Lake County and Cook County. Approximately 13 percent of the population throughout Northern Illinois are 65 years and older, which places a significant demand on a limited number of nursing home beds in facilities all throughout the state.

Waukegan Nursing Home Resident Bedsore Concerns

Our Waukegan bedsore abuse attorneys have long held negligent nursing care homes accountable when the residents have suffered preventable pressure sores. Our law firm has years of experience in handling bedsore injury cases and works hard to ensure the victim receives fair and just compensation for their damages.

In addition, our attorneys continuously review, evaluate and assess publicly available information from national databases including Medicare.gov. The data reveals opened investigations, filed complaints, safety violations and health concerns at nursing facilities all throughout Northeast Illinois. Many families use this information to make the best-informed decision before placing a spouse, parent or grandparent in a nursing facility.

Comparing Waukegan Area Nursing Facilities

Avoiding the development of a bedsore is usually easy if the nursing staff follows procedures and protocols and take necessary measures and provides treatment in a timely fashion. However, not every nursing home can ensure that a loved one will not acquire a bedsore while the resident is under their care.

The information below is a list of Waukegan area nursing facilities that currently maintain below average ratings compared to other nursing homes throughout the United States. In addition, our Illinois elder abuse law firm has posted our primary concerns by listing specific cases of bedsore problems that could have been prevented.

Sheridan Medical Complex

8400 Sheridan Rd
Kenosha, Wisconsin 53143
(262) 658-4141
A “For-Profit” 96-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
2 Star Rating

Primary Concerns –

Failure to Ensure Residents Receive Proper Treatment to Prevent New Sores from Developing and Promote Healing of Existing Bedsores

In a summary statement of deficiencies dated 07/20/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “ensure that for residents at risk of developing pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.”

The deficient practice was noted by a state investigator who observed the resident “in bed without his heels floating or being repositioned every two hours. Also, no barrier cream was used as ordered for skin protection.” The surveyor also noted that the resident had a Braden Score that assesses the potential risk of developing bedsores. The resident’s Braden Score was ranked 10, indicating “high risk for the development of pressure ulcers” (bedsores; pressure sores; decubitus ulcers).

The state surveyor reviewed a resident’s medical records between 07/01/2015 and 07/07/2015. In addition, the resident’s revised 02/18/2015 Skin Integrity Care Plan includes interventions of repositioning performed by the nursing staff every two hours or as needed “and elevate heels off bed/chair” which was revised in 06/15/2015.

A complete review of the resident’s 05/11/2015 Significant Change MDS (Minimum Data Set) documents that the resident “has no speech, rarely/never makes self understood, rarely/never understands others, has short and long-term memory problems and is severely impaired for cognitive skills for daily decision-making.” The document also notes of the resident is “dependent on staff for all of his ADLs (activities of daily living), is transferred with a Hoyer lift went to staff assist, does not ambulate and receives his nutrition and medication via a gastronomy tube [G tube]. The resident does not have a pressure ulcer.”

The documented 05/11/2015 CCA (Care Area Assessment) of the resident’s urinary incontinence and indwelling catheter notes that the resident “will be dry when wife visits […and] will be changed before and after meals, upon waking, hour sleep and as needed (PRN). His skin checked and application of moisture barrier will be applied.”

However, the state investigator conducted a 7:52 AM 07/02/2015 observation of the resident who was “in bed on his back. The head of his bed is elevated, there is a pillow under [the resident’s] head and under [the] right and left upper body. [The resident] has bilateral blue boots on his feet but both heels were resting directly on the mattress and are not floating.”

Later that same morning at 9:16 AM, the surveyor observed the resident who “continues to be in bed in the same position with the head of the bed elevated, pillows are under resident’s head and right and left upper body […and the resident still] has bilateral boots on but his heels were resting directly on the mattress and are not floating.”

Fifty minutes later at 10:06 AM, the same surveyor now observed a Licensed Practical Nurse (LPN) flushing the resident’s G-tube. During this observation, the LPN did not reposition [the resident who] continue to be in the same position” with heels resting on the mattress and not in a floating position.

Nearly an hour later at 11:04 AM, the surveyor observed two Certified Nursing Assistants (CNAs) entering the resident’s room. At that observation, both Certified Nursing Assistants wash their hands and placed gloves on when one CNA “remove the bedding off the resident’s [while the other CNA] removed the pillow from under [the resident’s] calves” while the resident’s heels were still not floating but resting directly on the mattress.

The surveyor notes that “after cares were completed, [both CNAs] transfer the resident into a high back wheelchair using a Hoyer lift […and] provided oral care and then wheeled the resident out of his room placing [him] in the hallway outside the nurses’ station.” The surveyor knows that at no time was the resident “repositioned every two hours according to his plan of care.”

Four days after the initial observation by the state investigator, the resident was once again observed at 7:52 AM on 07/06/2015 who was observed in the same position “on his back of the pillow under his head and under his right and left upper body […and] has bilateral boots on but his heels were resting directly on the mattress and are not floating.”

Nearly 2 hours later at 9:37 AM the state surveyor “observed that [the CNA] did not place any barrier cream on the resident after changing the resident.”

The state investigator then met with the facility Registered Nurse at 2:20 PM the following day on 07/07/2015 to discuss the resident and asked the Registered Nurse “if staff should apply barrier cream on [the resident] after an incontinent episode.” The Registered Nurse replied, “Yes.” The Registered Nurse also agreed that the resident’s feet should be floated as is indicated in the resident’s Care Plan.

Our Kenosha nursing home neglect attorneys recognize the failing to follow procedures and protocols for residents at risk of developing pressure ulcers could place their health and well-being in jeopardy. The deficient practice by the nursing staff at Sheridan Medical Complex might be considered negligence or mistreatment because the resident did not receive adequate care after being assessed as high risk for developing pressure ulcers.

Kenosha Estates Rehabilitation and Care Center

1703 60th St
Kenosha, Wisconsin 53140
(262) 658-4121
A “For-Profit” 97-certified bed Medicaid/Medicare-participating facility
Overall Rating – 3 out of 5 possible stars
3 Star Rating

Primary Concerns –

Failure to Ensure Residents Receive Proper Treatment to Prevent New Sores from Developing and Promote Healing of Existing Bedsores

In a summary statement of deficiencies dated 03/19/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “ensure that one resident with a pressure ulcer received appropriate treatment for the pressure ulcer.”

The deficient practice was noted by state investigator after review of a resident’s medical records noting the resident had “developed an unavoidable unstageable pressure ulcer to his/her left heel.”

The surveyor reviewed the resident’s 03/11/2015 medical record that indicates “on 02/26/2015 the resident developed a 1.0 centimeter by 1.0 centimeter dark necrotic area on the left posterior heel. Based on observation and interview, the pressure area was unavoidable.”

As a part of the review, it was noted that the resident “was ambulatory and fell in the dining room of February 2015 and complained of pain. The facility completed a full set of x-rays on [the same day] that indicated there was no fracture [but the resident] continued to complain of pain and another set of x-rays was taken [12 days later] on 02/20/2015 that also indicated no fracture.” However, the resident “continued to complain of pain and the physician ordered an MRI of the left hip [7 days later] on 02/27/2015 and this revealed a hairline [fractured] hip.

The surveyor noted that the resident “was non-compliant with floating heels would not wear the protective boot in bed.” The surveyor then conducted an interview on 03/11/2015 with the facility’s Wound Nurse who “indicated that the facility put interventions in place to protect [the resident’s] heels, but the resident was non-compliant with keeping his/her heels off the bed. She indicated that staff would always float the heels but the resident would kick the pillow away.”

That same day, the surveyor “observed the wound treatment to [the resident’s] heel” where it was observed that the Registered Nurse was “doing the treatment to the resident’s heel […and removed] the old dressing from the left heel […and] then moved the pillow that was in the bed and placed [the resident’s] open wound directly on the pillow that had been in the resident’s bed.” The Registered Nurse then “proceeded to complete the treatment and placed [the resident’s] heel on the same pillow that the wound was placed on.”

At 2:30 PM that same day, the state surveyor spoke with the Wound Nurse who indicated that the Registered Nurse “should have put something clean down on the bed and should not have placed the resident’s wound on the dirty pillow that was in the bed.”

Our Kenosha elder abuse attorneys recognize that failing to follow procedures and protocols when providing treatment to residents with an existing pressure ulcer could place their health and well-being in jeopardy. The deficient practice by the nursing staff at Kenosha Estates Rehabilitation and Care Center might be considered negligence or mistreatment because their actions failed to follow the facility’s revised October 2010 policy title Wound Care that reads in part:

“Staff should place a disposable cloth next to the resident (under the wound) to serve as a barrier to protect the bed linen and other body sites.”

Avantara Long Grove

1666 Checker Road
Long Grove, Illinois 60047
(847) 419-1111
A “For-Profit” 190-certified bed Medicaid/Medicare-participating facility
Overall Rating – 2 out of 5 possible stars
2 Star Rating

Primary Concerns –

Failure to Ensure Residents Receive Proper Treatment to Prevent New Sores from Developing and Promote Healing of Existing Bedsores

In a summary statement of deficiencies dated 08/06/2015, a state surveyor made a notation during an annual licensure and certification survey concerning the facility’s failure to “identify risk factors for skin breakdown and [a failure] to implement interventions to reduce or eliminate pressure to avoid pressure ulcer development.” The deficient practice of the nursing staff at Avantara Long Grove applies to four residents at the facility.

The deficient practice was noted by state investigator included a review of a resident’s MDS (Minimum Data Set) that revealed the resident “requires extensive assistance for dressing, hygiene, bed mobility and is totally dependent for bathing and transfers. In addition, the resident’s 07/20/2015 Plan of Care showed “staff is to apply a heel protector to [the resident’s] left heel at all times to prevent worsening skin condition. Provide a heel protector when resident is in bed to prevent the development of sore on the right heal. (Both heels).

However, a review of the resident’s 06/26/2015 Progress Note shows that the resident “had a left heel blood filled blister and was to have protectors applied while in bed. The resident’s 06/08/2015 Rating Scale for Predicting Pressure Sore Risk shows of the resident scored 19 which indicates no risk of pressure ulcer.

The resident’s 08/03/2015 Pressure Ulcer Report shows that the resident’s “left heel and right trochanter (hip) wounds developed after being admitted to the facility, and were first identified on 07/08/2015. The wound documentation listed [the resident’s] right trochanter (hip) pressure ulcer as a Stage II measuring 1.0 centimeters by 1.5 centimeters and his left heel wound was unstageable measuring 4.0 centimeter by 3.0 centimeter by 0.1 centimeters.”

The facility’s Wound Care Nurse stated at 12:00 PM on 08/05/2015 that the resident’s “wounds are facility acquired because he always goes on his right hip and his left heel is always on the bed.”

Our Long Grove nursing home neglect attorneys recognize a failing to follow procedures and protocols when providing treatment to residents at risk for developing pressure ulcers could place the resident’s health and well-being in jeopardy. The deficient practice by the nursing staff at Aventura Long Grove might be considered negligence or mistreatment because their actions failed to follow the facility’s revised February 2014 policy title: Policy and Procedure for Pressure Ulcers that reads in part:

“Identification of risk factors that impact developing unavoidable ulcer or will affect healing process if the resident does not have an ulcer. The following are risk factors: Cognitive loss. If in bed, position resident in bed with pillows or other support devices to protect bony prominence if susceptible to pressure. Place on pressure reduction or pressure relief surface in bed and wheelchair. Off load elbows and heels as needed. Elevate resident heels off the bed unless as indicated (e.g., place pillows under calf (not under ankles) to raise heels off the bed, unless contraindicated due to a medical condition).”

Waters Edge Rehabilitation and Care Center

3415 N Sheridan Rd
Kenosha, Wisconsin 53140
(262) 657-6175
A “For-Profit” -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 09/22/2015, a notation was made by a state investigator during an annual licensure and certification survey concerning the facility’s failure to “ensure that one resident with pressure ulcers receive the necessary treatment and services to promote healing and prevent new ulcers from developing.”

The deficient practice was noted by state surveyor noting that a resident “has a facility-acquired state to pressure ulcer on the left outer foot. The facility investigated the root cause of the pressure ulcer and determined it developed on 09/10/2015, either due to the pressure redistribution boots sliding when the resident moved around in bed or from the positioning of the foot on the footboard of the bed.”

The surveyor also noted that “after the development of the pressure ulcer, the facility obtained a larger bed for [the resident] and discontinued the pressure redistribution boots. The Plan of Care was updated to include floating the resident’s heels and discontinuing pressure distribution boots.”

The state investigator observed the resident on 09/15/2015 “in bed with his heels floated and he was wearing his roommate’s pressure redistribution boots.”

A complete review of the resident’s Admission MDS (Minimum Data Set) indicates the resident “has severely impaired cognition, requires total staff assistance for bed mobility and transfers, is 72 inches in height, is at risk for pressure ulcers, and was admitted with one Stage II Pressure ulcer.”

The resident’s Braden Scale for Predicting Pressure Sore Risks conducted on 06/25/2015, 09/15/2015 and 08/30/2015 indicate that the resident “is at high risk for pressure ulcer development.” In addition, the 06/26/2015 Plan of Care for Skin Impairment “includes the interventions for bilateral heel boots.”

The facility’s 07/01/2015 Occupational Therapy – Therapist Progress Notes included “the clinical impression that the resident continues in a twin size bed decreasing the ability to fully achieve side lying. Impression indicates to continue recommending larger bed for easier cares and repositioning.” An additional notation is made one week later on 07/08/2015 in the OT Therapist Progress Note that includes “the clinical impression that the facility declined use of a larger bed for the resident stating the resident size does not indicate the need.”

The state investigator reviewed the resident’s SBAR (Situation, Background, Assessment and Recommendation) form that indicated “that during morning cares [the resident] was observed to have developed a blister to the left outer foot. The form indicates the physician was notified, new orders were received for skin prep, the heel boots were discontinued and the resident’s heels were free to be floated.”

The resident’s 09/11/2015 Nurse’s Notes made as a 09/10/2015 3:00 PM Late Entry Date indicated “a blister was observed on the resident’s left outer foot, the resident’s heel boots were discontinued and the resident is receiving a larger bed for more room.”

Notations made the same day in a 09/10/2015 Weekly Wound Assessment indicates that the resident “has a 5.0 centimeter by 3.5 centimeter pressure ulcer to the left outer foot. The pressure ulcer assessment is described as a blood blister […and] indicates treatments to include discontinuing the heel boots and free-floating the heels.”

Observations made at the facility of the resident’s pressure ulcer on 09/10/2015 indicates that “the pressure ulcer was caused by pressure or friction to the foot […and] the foot or boot may be rubbing on the footboard of the bed, that the resident is tall, and that the bed may not be long enough for the resident to be positioned without friction/contact to the foot board.”

Five days later, the surveyor made an observation with the facility’s Licensed Practical Nurse at 10:05 AM on 09/15/2015 noting that the resident “had bilateral heel boots on.” One Licensed Practical Nurse at the observation “indicated the resident’s heel boots were discontinued and the resident should not be wearing the heel boots […and indicated] the heel boots belonged to the resident’s roommate and they must have been put on by a third shift staff.

25 minutes later at 10:30 AM, the surveyor spoke to the facility Registered Nurse who also serves as the Wound Nurse. The Wound Nurse indicated that the resident “developed a fluid-filled blister on 09/10/2015 from rubbing of the heel boots or from pressing against the footboard of the bed […and] indicated the area was assessed and the root cause analysis was completed.” The Wound Nurse also indicated “that the resident should have his heels free floated with pillows and should not be wearing heel boots.”

The surveyor then conducted an interview at 2:35 PM on 09/21/2015 with the facility’s Director of Nursing “who indicated that on 07/01/2015, [the Occupational Therapist] recommended a wider bed for the resident [… but] indicated the resident did not meet the qualifications of a bariatric bed and one was not provided to the resident.” However, the Director of Nursing indicated that “on 09/10/2015, after the resident developed the pressure ulcer to the left outer foot, a wider and longer bariatric bed was provided to the resident.”

Our Kenosha nursing home neglect lawyers recognize that failing to provide proper equipment as part of the treatment to allow an existing pressure ulcer to heal could jeopardize the health and well-being of the resident. The deficient practices by the nursing staff at Water’s Edge Rehabilitation and Care Center might be considered negligence or mistreatment because their actions did not follow recommendations for a larger bed led to the worsening of a resident’s wound.

Glenlake Terrace Nursing and Rehabilitation Center

2222 West 14th Street
Waukegan, Illinois 60085
(847) 249-2400
A “For-Profit” 265-certified bed Medicaid/Medicare-participating facility
Overall Rating – 3 out of 5 possible stars
3 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 04/21/2015, a complaint investigation was opened against the facility for its failure to “implement preventative measures to prevent the development of a facility acquired pressure ulcer.” The deficient practice by the nursing staff at Glenlake Terrace Nursing and Rehabilitation Center affected one resident at the facility.

The complaint investigation included a review of the resident’s MDS (Minimum Data Set) of 02/02/2014 and 05/01/2014 revealing of the resident “required total assistance for bed mobility and transfer.” The documented Skin and Ulcer Treatments section “did not show that the resident was on a Turning and Repositioning Program.”

Upon review of the resident’s 04/20/2015 Wound Report documented by the facility’s Wound Nurse, the resident “had a Stage II pressure ulcer to the right buttock when admitted [to the facility and] also had a boil on the back the right ear that was infected on 05/22/2014.” The documentation also noted that the resident had “a Stage III pressure ulcer to the left malleolus on 05/24/2014.”

The resident’s clinical record also contained a wound assessment/report indicating “that there was no documentation how the pressure ulcer had progressed to a Stage III without having it noticed when it was still at an earlier Stage I and Stage II.”

The notation was made of the resident “was identified as high risk for developing a pressure ulcer. However, the nursing staff “had no explanation how the left malleolus was noted with the Stage III pressure ulcer without having a notice when it was newly developed as a Stage I and Stage II.”

A review of the resident’s 05/09/2014 Care Plan with a 07/30/2014 Goal Date and 06/04/2014 Care Plan with a 08/04/2014 Goal Date indicated “that there was no specific or individualized intervention regarding turning and repositioning to prevent further development of the new pressure ulcer. There was also no indication that [the resident’s] heels were off the bed for pressure relief.”

The state investigator reviewed the resident’s Care Plan with the facility Director of Nursing on 04/20/2015 who “stated that turning and repositioning schedule was not specified in the Plan of Care.”

Our Waukegan nursing home neglect attorneys recognize the failing to follow procedures and protocols when providing treatment to a resident with a pressure ulcer could lead to the degradation of the wound and jeopardize the health and well-being of the resident. The deficient practices of the nursing staff at Glenlake Terrace Nursing and Rehabilitation Center might be considered mistreatment or negligence because their actions failed to follow the facility’s Pressure Ulcer policy that reads in part:

“Turn and reposition residents at least every two hours. Keep heels off the surface at all times.”

Lake County Nursing Facility Neglect

Every year, thousands of residents in nursing facilities become victims of mistreatment and neglect, suffering debilitating pain from preventable bedsores. In some cases, the complications of an open wound will lead to an extensive hospital stay, surgery, amputation and or slow recovery. Usually, the most typical complication involves infections that placed the health and well-being of the resident in immediate peril. Some residents die as a result of a facility acquired pressure sore after the nursing staff has allowed the wound to become too severe for intervention or treatment.

Usually, residents who have diminished mobility are at the highest risk for facility acquired pressure sores, no matter what other health concerns are involved or the individuals age. The condition of a small wound can quickly deteriorate into a life-threatening problem within days. Many residents in nursing facilities succumbed to the facility acquired bedsores without an advocate overseeing the care or lack of care provided by the nursing staff.

The Rights of the Resident

The staff in a nursing facility is legally bound to take every necessary precaution to ensure that bedsores are prevented. This responsibility includes aggressively identifying a bedsore in its first stages and then taking necessary precautions to ensure it heals quickly. The action of the nursing staff often involves turning and repositioning the resident’s body to alleviate pressure at a minimum of one time every two hours or less. Any lack to do so could be seen as negligence or mistreatment of the resident.

Hiring a Lawyer to Prosecute a Waukegan Nursing Home Negligence Case

If you suspect your loved one has been injured, abused, mistreated or neglected while residing in any Illinois nursing facility, the Waukegan nursing home abuse attorneys at Rosenfeld Injury Lawyers LLC can help. Our elder abuse law firm has successfully represented elderly clients who were subjected to neglect while residing in a nursing facility in Illinois, Indiana, and Wisconsin.

We encourage you to make contact with our Lake County, Illinois elder abuse law office today by calling (800) 926-7565 to schedule your no obligation, free full case review. All cases are handled through contingency fee arrangements. This means our fees are only paid after we win your case at trial or negotiate an acceptable out of court settlement.

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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