With her last dying breath, the last word to pass through Samuel Lee Beard’s lips was “home.”
By her family’s accounts, the final months of the 77-year-old stroke patient’s life while a resident at Evergreen Health Care Center, a nursing home and rehabilitation with a spotty regulatory history, were pure hell.
Completely immobilized by a stroke, Beard’s skin was eaten by bed sores when she died in May 2007. The woman’s granddaughter, Vania Beard, maintained the sores were the result of not being turned properly while in the care of the Evergreen Park nursing home.
Last month, Beard’s granddaughter reached a $575,000 settlement with the owners-–Evergreen Health Care Center LLC—on charges that the facility failed to “properly prevent, monitor and treat Ms. Beard’s bed sores, and these injuries contributed to her death.”
Beard entered Evergreen after suffering a debilitating stroke in February 2007, where she spent the last four months of her life.
“A lot of times we came in on weekends and evenings and she smelled like she hadn’t been changed,” her granddaughter said. “Other patients complained that she smelled too.”
On one occasion, the family discovered that her feeding tube had loosened from the machine. Vania Beard also observed that her grandmother, whom family members visited every day, was never turned.
"Every bed sore she developed my family found,” Vania said. “Not the Evergreen staff members who were paid to take care of her.”
Years of state inspection reports between 2005 and 2010, when Evergreen’s state license was nearly revoked, reveal a pattern of violations involving the grave endangerment of patients.
“They have a very substantial and negative regulatory history,” Beard’s attorney Steven Levin said. “In our opinion when a facility has repeated instances of violations and frequent lawsuits that's usually a sign that they’re insufficiently staffed or improperly trained or supported by administration.”
Beard’s overall condition had worsened as a result of her bed sores to where she was diagnosed with sepsis, dehydration and pneumonia, Levin said.
Of the four cases that Levin’s personal injury law firm—Levin and Perconti—has pending against Evergreen Health Care Center, LLC, two involve bed sores. The others involve a patient falling and another for improper monitoring of anti-coagulation medicine.
At least 25 lawsuits have been filed against the nursing home between 2001 and 2012, according to Cook County court records.
Evergreen became the target of a Chicago Tribune investigation in 2010, when the state threatened to revoke the nursing home’s license. The report cited medication errors, falls, injuries and instances of extreme neglect documented by state health officials.
One of the most grievous violations involved an 86-year-old skin cancer patient whose head was found to be infected with maggots. Evergreen contested the 2010 revocation before an administrative law judge, the Tribune reported.
The pattern of violations also landed Evergreen on a federal nursing home watch list, that cited 15 complaints where patients were harmed or put in jeopardy between 2009 and 2011.
A consultant contacted by Patch said the nearly six-year-old case involving Samuel Lee Beard was “closed with no admission of liability.”
“Rather, the settlement is indicative of a desire to reach closure and avoid ongoing legal fees,” Liana Allison, Evergreen’s spokeswoman said via email.
Since April 2011, Evergreen Health Care Center has been under new management. Allison pointed out the positive changes taking place at the facility, including hiring more registered nurses “four times the state’s required percentage.”
Staff members have completed nearly 5,000 hours of staff development and training annually; and physician leadership and presence in the building “has quadrupled.”
Evergreen has also earned the Joint Commission on Accreditation of Healthcare Facilities Gold Seal of Approval, the consultant said.
Further, Allison wrote, there have been no substantiated complaints filed against Evergreen Health Care in the past year.
Levin said that while ownership of the for-profit nursing home and rehabilitation center has remained the same, oftentimes owners will frequently change management companies, as in the case of Evergreen.
One of the listened owners is Chicago financier Harrison Steans, whose daughter, Illinois State Senator Heather Steans (D-Chicago), divested her 2.8-percent interest in the troubled nursing home after the 2010 revocation action.
“When owners put profits over people, or don’t provide the nursing home with sufficient funding to hire an appropriate amount of staff and adequately train them, these types of tragedies occur,” Levin said.
Until her stroke, Samuel Lee Beard was the matriarch of four generations of family members that lived together under one roof in Chicago. Vania Beard said given her grandmother’s condition of total dependency, that Evergreen never should have taken her.
Asked what she would tell other families seeking long-term care for parents and grandparents?
“A nursing home has an obligation to report certain conditions,” Vania Beard said. “The state is supposed to investigate complaints from hospitals, family members and law enforcement agencies and post those results on the web. I didn’t do my research.”