Resident #10 had been ordered to keep all weight off their right foot since July 9. The Director of Nursing didn't notice the order until August 11 — more than a month later. During that time, the resident continued walking on the injured foot, pulling off wound dressings at night and removing them entirely for showers.
The facility's physician never received any communication about these problems. He told inspectors on August 13 that he expected the resident to use "a walker, wheelchair or whatever Resident #10 would use to be offloading on his/her right foot."
Instead, staff had refused to provide crutches. The Social Services Director told inspectors that residents weren't allowed crutches "because in the past residents used them as a weapon."
Resident #9 faced similar neglect with an infected wound on their left foot. The resident cleaned their own wound rather than receiving proper nursing care. They missed scheduled medical appointments and arrived at others without shoes, exposing the open wound.
"The residents should not be allowed to leave the facility without dressings covering their feet," the physician said. "There had been times when the residents' arrived at their appointments without a dressing covering their wounds."
The nursing staff's failures created a cascade of medical risks. When residents removed their own dressings or walked on injured feet, staff never reported the non-compliance to the physician. The Director of Nursing told inspectors she "expected nurses to call and report non-compliance for dressing changes or non-weight bearing status to the physician," but no such calls were made.
The facility's communication system broke down at multiple points. When residents returned from medical appointments, the receptionist was supposed to scan their paperwork and distribute copies to the Director of Nursing, medical records, and the attending nurse. New orders were supposed to be entered promptly.
None of this happened consistently. The Director of Nursing discovered Resident #10's month-old non-weight bearing order only when she happened to review the file. She told inspectors she "just saw the order yesterday" and had finally "added it to the resident's POS."
The physician expressed frustration with the facility's failures. He never received communication about Resident #9's non-compliance with foot offloading, missed appointments, or incomplete dressing changes. He was unaware that Resident #10 was removing dressings and refusing wheelchair use.
"He would expect the nursing staff to provide all wound care and not allow Resident #9 to clean his/her own wound," inspectors documented.
The medical consequences were severe. Both residents had infected foot wounds requiring careful monitoring and treatment. The physician warned that "when the facility did not follow his wound care orders, the residents were at risk for infection and amputation."
Proper wound care requires sterile technique and clinical expertise. Allowing residents to clean their own wounds exposes them to dangerous bacteria and prevents proper assessment of healing progress. Walking on infected feet can worsen wounds and spread infection to bone.
The Social Services Director acknowledged that Resident #10 needed "a referral to evaluate" their mobility needs, but no such referral had been made despite the obvious problems with weight-bearing compliance.
The inspection revealed a pattern of nursing staff failing to follow basic wound care protocols. Residents were left to manage their own medical care while staff ignored physician orders and failed to communicate critical changes in condition.
Federal inspectors found the facility's failures placed residents at risk for serious harm, including infection and potential amputation. The violations occurred despite clear physician orders and established facility policies requiring nursing staff to provide wound care and monitor compliance with medical restrictions.
The physician's warnings about amputation risk underscore the serious medical consequences when nursing homes fail to follow wound care orders. Both residents continued to face these risks while staff remained unaware of or indifferent to their physician's specific instructions for preventing further injury.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Village Park from 2025-08-13 including all violations, facility responses, and corrective action plans.