Licensed Practical Nurse N found the resident on his right side around 4 p.m. on August 5th at Villa at Parkridge. She helped him back into bed and documented that he had no injuries and no pain after what she called a "body assessment."
Nobody notified the resident's physician. Nobody called his guardian.
The next morning, the resident complained to an occupational therapist about right hip pain and mentioned he had fallen the day before. The therapist immediately notified nursing staff.
Later that same day, the resident's guardian arrived for a visit. The guardian learned about the fall not from facility staff, but from the resident's roommate. The guardian went directly to administration and demanded the resident be sent to the hospital immediately.
Hospital records revealed the resident had sustained a right hip fracture that required surgical repair.
The resident, identified in inspection records as R3, had scored 13 out of 15 on a mental status assessment, indicating good cognitive function. Yet when staff found him next to his bed on August 5th, he was unable to articulate what had happened.
Licensed Practical Nurse N and Certified Nursing Assistant O placed him back in bed. A nursing note written two days later as a "late entry" stated that a body assessment was conducted and the resident had no injuries or pain.
But the assessment was incomplete. Staff performed no range of motion checks on his extremities. No neurological evaluations were documented. The resident's physician was never contacted about the incident.
During a phone interview with inspectors, LPN N acknowledged she found the resident on the floor on his right side. When asked about her assessment, she said the resident denied pain and that "neuro checks were initiated" but she wasn't sure if they were documented.
She described her body check as looking over the resident's body for cuts, abrasions, and bruises. When asked if she performed any range of motion testing, she said no.
When inspectors asked why she failed to notify the resident's physician and guardian, LPN N said she "didn't have a reason, she just didn't."
Assistant Director of Nursing C told inspectors that nobody was aware the resident had fallen until the occupational therapist reported it. She said LPN N was aware but "forgot to document it and pass the information along."
When asked why the physician and guardian weren't notified until the day after the fall, the assistant nursing director said they had just found out and hadn't had a chance to contact them before the roommate told the guardian.
Director of Nursing B confirmed during an interview that facility policy required staff to notify the physician and responsible party after any fall or incident once the resident was fully assessed and deemed safe.
The fall investigation, which included hospital records, documented that the resident sustained a right hip fracture requiring surgical repair. He was transferred to the hospital on August 6th, more than 24 hours after staff found him on the floor.
The resident had been admitted to Villa at Parkridge on an unspecified date before the August 5th incident. His cognitive abilities, as measured by the Brief Interview for Mental Status, showed he retained most of his mental faculties.
Yet no documentation from August 5th indicated he had fallen. The only record of the incident was the late entry nursing note dated August 7th, written after the resident had already been hospitalized and his hip fracture discovered.
Federal inspectors cited the facility for failing to provide appropriate treatment and care according to orders and resident preferences. The violation was classified as causing minimal harm or potential for actual harm.
The case illustrates a breakdown in basic nursing protocols. A resident suffered a serious injury that went undiagnosed for over 24 hours because staff failed to conduct proper assessments or notify appropriate parties after finding him on the floor.
The resident's guardian learned of the fall only by chance, through a conversation with the resident's roommate during a routine visit. Without that disclosure, the fractured hip might have gone undetected even longer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villa At Parkridge from 2025-08-20 including all violations, facility responses, and corrective action plans.