The resident at Avantara Lake Zurich told federal inspectors she felt "frustrated and humiliated" during her first night at the facility in August, then "helpless" and "scary" as she realized nobody was coming to assist her.
"She had to go to the bathroom and couldn't find her call light," according to the inspection report. The woman uses a bedpan because of her fractured pelvis and is working with therapy to eventually use the bathroom independently.
"No one was coming to check on her and she ended up going in her brief," inspectors documented. "She was sitting in urine and yelling for someone to come help her."
The woman, identified in the report as a former nurse who is "alert and oriented," called emergency services out of desperation.
Only when police contacted the facility did staff respond. Licensed Practical Nurse V5 told inspectors he received a call from police saying the resident in her room "needed help and couldn't find her call light."
V5 went to the woman's room and asked if she had called 911 and what she needed. She told him she couldn't locate her call light, needed to use the bedpan, and required changing. V5 said he would send a nursing assistant to help, then left to return to the police call.
Certified Nursing Assistant V7 confirmed the woman's account when he finally arrived. "Her call light was tied to the bed rail, but R1 said she didn't see it there," the inspection report states. "R1 was very frustrated about not being able to use the bedpan and being wet."
V7 found the resident's brief soaked with urine.
The incident occurred during the woman's first night after admission from a hospital. Medical records show she arrived via stretcher with paramedics, diagnosed with a closed fracture of her left inferior pubic ramus that did not require surgery.
Registered Nurse V4, who cared for the woman the day after her admission, received the incident in report from the previous nurse. V4 told inspectors the woman "reported to her that she was waiting for over an hour for someone to come around, no one was coming and she needed help, couldn't find the call light so she called 911."
"R1 was very frustrated and should not have to feel like that," V4 told inspectors.
The nursing assistant who responded noted a critical detail about the call light placement. While V7 found it tied to the bed rail, the resident said she couldn't see it there during her hour of distress.
The woman's medical background as a former nurse made the situation particularly striking to staff. V4 specifically noted that the resident "is a former nurse, is alert and oriented, and knows when she needs to use the bed pan."
Federal inspectors cited Avantara Lake Zurich for failing to ensure the resident was treated with dignity, violating regulations requiring facilities to honor residents' rights and promote self-determination through support of resident choice.
The facility's own Privacy and Dignity Policy, dated just weeks before the incident, states "it is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times."
Yet the woman's first-night experience contradicted that policy entirely. She moved slowly as she sat up in bed during the inspector's visit, recounting how her need for basic toileting assistance escalated into a police matter.
The progression of her emotions during the incident reveals the human cost of inadequate staffing response. What began as frustration over a missing call light became humiliation as she soiled herself. The humiliation transformed into fear as she realized the isolation of her situation.
Her decision to call 911 represented a desperate attempt to access help when the facility's systems failed her completely. The fact that police intervention was required to prompt basic nursing care highlights the breakdown in fundamental resident services.
The woman's account suggests she spent considerable time calling out for assistance before resorting to emergency services. Her description of "yelling for someone to come help her" indicates sustained attempts to get attention through traditional means before escalating to police contact.
The timing of staff response only after police intervention raises questions about monitoring protocols and staff availability during overnight hours. The woman's wait of "over an hour" for assistance with basic toileting needs represents a significant gap in care for someone with limited mobility due to her pelvic fracture.
The incident occurred despite the resident's alert mental status and clear communication abilities. Her background as a former nurse likely made her particularly aware of appropriate care standards, making the experience even more distressing as she recognized the inadequacy of her treatment.
The woman's broken pelvis requires her to depend entirely on staff assistance for toileting needs, making timely response to her calls essential for maintaining dignity and preventing exactly the type of incident that occurred during her first night at Avantara Lake Zurich.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avantara Lake Zurich from 2025-08-26 including all violations, facility responses, and corrective action plans.