Bedsores in Nursing Homes: When Pressure Ulcers Are Neglect

Bedsores — also called pressure ulcers or pressure injuries — are among the most visible and preventable signs of nursing home neglect in Illinois. When a resident develops a Stage 3 or Stage 4 pressure injury, federal regulators generally treat that wound as avoidable, meaning facility staff should have prevented it with proper care. If your family member has been harmed by nursing home bedsores neglect in Illinois, understanding what the law requires and what your options are is an important first step.

This article provides general legal information; consult with a licensed Illinois attorney for advice specific to your situation.

What Are Pressure Ulcers and How Are They Staged?

A pressure ulcer forms when sustained pressure cuts off blood flow to the skin and underlying tissue, causing the tissue to break down. The National Pressure Injury Advisory Panel (NPIAP) — the leading clinical authority on pressure injuries — defines four primary stages plus an unstageable category:

• Stage 1: Intact skin with non-blanchable redness. The area may feel firmer, warmer, or softer than surrounding tissue.
• Stage 2: Partial-thickness skin loss involving the epidermis and possibly the dermis. Presents as a shallow open ulcer or intact blister.
• Stage 3: Full-thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. Depth varies by location.
• Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. These wounds can extend into muscle or supporting structures, carrying a serious risk of life-threatening infection.
• Unstageable: Full-thickness skin and tissue loss where the base of the wound is obscured by slough or eschar, preventing accurate staging until the wound bed is exposed.

From a legal and regulatory standpoint, the stage matters enormously. The Centers for Medicare & Medicaid Services (CMS) has long held that Stage 3 and Stage 4 pressure ulcers are almost always avoidable in a compliant facility — a position grounded in decades of clinical evidence that routine repositioning, skin assessments, and pressure-relieving surfaces can prevent even high-risk wounds.

Federal Standards: What Nursing Homes Are Required to Do

Federal law sets a baseline floor for every Medicare- and Medicaid-certified nursing facility in the country. Under 42 CFR 483.25(b) — the Quality of Care regulation covering pressure ulcers — a facility must ensure that:

• A resident who enters the facility without pressure ulcers does not develop them unless the individual’s clinical condition makes them unavoidable.
• A resident who enters with pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.

The Agency for Healthcare Research and Quality (AHRQ) has published comprehensive pressure ulcer prevention guidelines that inform what “necessary treatment and services” looks like in practice: regular skin assessments on admission and at intervals thereafter, individualized care plans addressing repositioning schedules, nutritional support, moisture management, and use of pressure-redistributing surfaces.

When a nursing home fails to follow these protocols and a resident develops a serious wound, the gap between what was required and what was provided is the core of a neglect claim.

Illinois Law: Nursing Home Neglect Defined

Illinois has its own statutory framework governing nursing facility residents. Under 210 ILCS 45/1-117, “neglect” is defined as a facility’s failure to provide adequate medical or personal care or maintenance, when that failure results in physical or mental injury to a resident, deterioration of the resident’s physical or mental condition, or deprivation of services necessary to maintain the resident’s physical or mental health. A worsening pressure ulcer caused by missed repositioning schedules, inadequate wound care, or understaffing fits squarely within that definition.

The Illinois Nursing Home Care Act gives injured residents — and their families — a private right of action against facilities that violate the Act’s standards. Importantly, the statute also provides for the recovery of reasonable attorney fees and costs when a resident prevails, which means families are not automatically priced out of bringing a claim. You can explore additional protections under our nursing home abuse resources.

Signs That a Bedsore May Constitute Neglect

Not every pressure ulcer is evidence of legal neglect — some residents present with conditions so severe that even perfect care cannot prevent skin breakdown. But certain circumstances raise serious questions about whether a facility met its legal obligations:

• A Stage 3 or Stage 4 wound developing on a resident who had no pressure injury on admission
• No documented repositioning or turning schedule in the medical record
• Missing or inconsistent skin assessment entries
• A care plan that fails to address known risk factors such as incontinence, limited mobility, or poor nutrition
• Evidence of understaffing — such as call logs, staffing reports, or staff-to-resident ratios below required minimums
• A wound that worsened because it went unnoticed or untreated for an extended period
• Signs of infection that were not promptly addressed

Medical records, nursing notes, and facility inspection reports from the Illinois Department of Public Health (IDPH) are often key sources of evidence in these cases.

What Families Can Do When They Suspect Neglect

If you discover that a loved one in an Illinois nursing home has developed a serious pressure ulcer, there are several immediate steps you can take:

• Request complete medical records right away, including nursing notes, physician orders, care plans, and wound-assessment documentation. Illinois law entitles residents and authorized family members to these records.
• Photograph the wound (with the facility’s knowledge or through the attending physician) and note the date, time, and location on the body.
• File a complaint with IDPH at 1-800-252-4343 or through the online complaint portal at dph.illinois.gov. An IDPH survey visit can produce a state inspection report that documents deficiencies and becomes useful evidence in a civil case.
• Contact the Illinois Long-Term Care Ombudsman at 1-800-252-8966. Ombudsmen can advocate for residents and help navigate complaints at the facility level.
• Consult an attorney as early as possible. Illinois has a statute of limitations on personal injury and nursing home neglect claims, and evidence can be lost or altered if action is delayed.

Talk to a Chicago Attorney — Free Consultation

If you or a family member has been harmed, the attorneys at Phillips Law Offices are ready to help. Call (312) 346-4262 or contact us online for a free, no-obligation consultation. We handle cases throughout the Chicago metropolitan area.