The Illinois Department of Health has cited and fined Goldwater Care Peoria Heights in Peoria Heights, Illinois when the facility failed to identify, assess, treat, and prevent the worsening of pressure ulcers for two bedbound residents — one who developed a Stage 4 pressure wound under the facility’s care that progressed to suspected bone infection, and another whose existing Stage 4 wound worsened amid repeated missed treatments, absent monitoring, and missing equipment. Both residents were hospitalized for sepsis, and the state issued an Immediate Jeopardy citation, the most serious level of violation.
The first resident was a 60-year-old woman who was admitted to the facility with no wounds. She was severely cognitively impaired, completely dependent on staff for all care, and her risk assessment shortly after admission classified her as “very high risk” for developing pressure ulcers. Despite this clear identification of risk, her care plan contained no plan for pressure ulcer prevention and no interventions to prevent one from forming. Several weeks later, a certified nursing aide identified an open wound on the resident’s coccyx and notified the wound nurse. The wound was identified after admission despite the resident previously having no documented wounds. Over the following weeks, treatments were ordered but documented as not completed on numerous occasions. The wound progressed from Stage 3 to Stage 4 with deep tunneling, copious purulent drainage, and a strong odor.
The resident’s condition declined further. She became clammy, short of breath, and was sent to the hospital, where she arrived with reported fevers and lethargy. She was admitted with a diagnosis of sepsis. The hospital’s records noted that staff there attempted to call the facility multiple times the following day to determine how long the resident had been ill — and no one at the facility answered the phone. Hospital imaging suggested osteomyelitis involving the sacral area. A licensed practical nurse who worked nights at the facility later told investigators in her own words: “Wound care would be the last thing we would do if we could even get to it. If I was working and the treatment was left blank it would mean I didn’t do it due to not having enough time.”
The second resident had been admitted to the facility with an existing Stage 4 pressure wound on his coccyx. His physician had ordered a rectal tube to help prevent contamination of the wound. Treatment orders were detailed and specific — including wound vacuum dressings on a set schedule and topical sodium hypochlorite applications every 12 hours. Multiple weeks of treatment records show repeatedly missed wound treatments and missed sodium hypochlorite applications. There is no documentation of daily skin assessments throughout his stay. There is no documentation that the rectal tube was monitored as required. No laboratory results appear in his medical record at all during his entire admission. After the rectal tube fell out, the facility could not get a replacement because the supplier was out of stock — and the facility never reached out to the hospital to obtain one. The medical record does not document that the tube was ever replaced.
The resident’s family member described what she observed in stark terms: “His wound is to the bone and the size of a plum, and when staff clean his bowel contents up, the pad over his wound also becomes soiled. I have seen that stool-soaked wound pad sit for over four hours before a nurse changed the wound dressing.” The resident was hospitalized twice for sepsis during this period. The emergency room physician stated the sepsis could have originated from multiple sources, including the Stage 4 ulcer with osteomyelitis, and noted that even without stool involvement, improper wound care alone can cause infection. The Director of Nursing acknowledged she had been unaware that the resident was not receiving wound treatments, was not being assessed for skin changes, was not having ordered labs done, and was not having his rectal tube monitored.
Across both cases, the same patterns emerged: documented failures to follow physician orders, absent or inadequate care plans, missing skin assessments, and staff reporting that wound care often could not be completed because of workload and time constraints. The facility’s wound nurse confirmed that for the first resident, no care plan for the wound had ever been entered into the system. For the second resident, the rectal tube — a key intervention to protect his wound — was not even on his care plan. The facility’s own policies required weekly wound assessments, daily skin checks, prompt physician notification, and care plans to be revised when skin integrity changed. None of these requirements were consistently met for either resident.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Illinois nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
