Resident #85 had been admitted to Village Health & Rehabilitation in July after complications from a right hip replacement. On August 9, during what should have been a routine transfer, her leg got caught and she fell when the nurse abandoned her in an unstable position.
"The nurse went to get help and left her standing at the edge of the bed with nothing to hold on to," the resident told inspectors.
The fall left her in agony. By 10:45 that night, she reported "intolerable pain 10/10 above her right knee." Her leg looked "a little bent/twisted out of shape going inward" and she couldn't use it for support. Any movement made the pain worse.
Staff member O, who was on duty during the fall, admitted to inspectors that he never called the physician on call. He acknowledged this delayed the resident's care "by a couple of hours."
The facility's own policy requires immediate physician notification for any accident that potentially requires medical intervention. Staff member B confirmed this protocol during interviews, stating the fall procedure was "to notify everyone of the fall, including the family and the doctor."
Nobody followed it.
Medical records show no documentation that any physician was contacted about the fall on August 9. The resident spent hours in excruciating pain while staff failed to seek medical guidance about her obvious injury.
It wasn't until 7:40 p.m. on August 11 that someone finally called the on-call provider to send the resident to the emergency department. By then, she had endured two days of untreated fracture pain that she rated as maximum intensity.
The delay had real consequences. Federal inspectors noted that the failure to notify the physician "impacted the physician's opportunity to provide directives on the resident's care, pain, and injury."
During the inspection, facility administrator staff member A tried to produce a document claiming the provider had been notified at the time of the fall. Inspectors clarified that staff member O had already admitted he never made the required call.
The facility's Fall Prevention Program, last updated in January, explicitly states that when a resident falls, staff must "notify physician and family." The policy on notification changes, reviewed as recently as October 2024, requires documenting "the date and time of the notification" in the resident's clinical record.
No such documentation exists for resident #85's fall.
The resident's electronic health record contains a stark timeline of neglect. The initial fall documentation at 3:07 p.m. on August 9 makes no mention of physician notification. The next entry doesn't appear until August 11, when someone finally documented the emergency department transfer request.
Between those entries lies a 48-hour gap during which an elderly woman with a fresh hip replacement surgery suffered with an untreated fracture because staff couldn't be bothered to pick up the phone.
Staff member O's admission that he "did not notify the physician on call" after the fall represents a fundamental breakdown in basic medical care protocols. His acknowledgment that this delayed treatment shows he understood the consequences of his inaction.
The case illustrates how quickly routine care can become dangerous when staff ignore established safety procedures. A simple transfer became a serious injury. A required phone call became a multi-day delay in treatment.
Resident #85 came to Village Health & Rehabilitation to recover from hip surgery complications. Instead, she found herself abandoned during a vulnerable moment, left to fall, and then ignored while she suffered with a fracture that could have been treated immediately if anyone had followed the facility's own policies.
The woman who needed support during her recovery was literally left standing without support. When she fell, the system failed her again.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Village Health & Rehabilitation from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
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