Abbington Village Nursing: Incontinence Care Failures - IL
That resident, identified in inspection records as R7, had hemiplegia and dementia. He was dependent on two staff members and a mechanical lift just to be moved. He couldn't change himself. He couldn't get up and find someone. He could only wait.
He told inspectors on September 24, 2025, that it had taken over an hour for staff to arrive after he needed a change. His care plan noted that he became upset after five minutes without a response and would allege he had been waiting for hours. The facility treated that as a behavioral quirk to be documented. The inspection record suggests it was an accurate account of what was happening to him.
A second resident, R9, described the same pattern. She had suffered a cerebral infarction that left her with hemiplegia affecting her left side. She was completely dependent on staff for toileting hygiene, always incontinent of both bowel and bladder, and required two staff members and a mechanical lift for transfers. Her care plan required incontinence care after each episode. She told inspectors on September 25 that she usually waited an hour for CNAs on both the first and second shifts to arrive and change her.
Usually. Not once. Usually.
A third resident, R1, had a certified nursing assistant who acknowledged she had never asked him whether he needed his brief changed during her shift. Her explanation was that R1 typically asks on his own. The facility's restorative aide said she had offered R1 a shower that morning and he declined, saying he was scheduled for one in the afternoon. The aide added that R1 had never told her he didn't want his brief changed until the PM shift. Nobody had asked.
The administrator, identified as V1, told inspectors on September 25 that nursing staff should check incontinent residents every two to three hours regardless of whether a resident can speak up for themselves. The restorative aide said the same thing. The facility's own incontinence care policy, though undated, states residents are to be changed every two hours and more frequently if needed.
The policy existed. The knowledge existed. The practice did not.
What makes the situation at Abbington Village particularly stark is who these residents are. R7 and R9 both had hemiplegia. Both required mechanical lifts and two-person assists. Neither could independently manage their own incontinence care under any circumstances. They were, in the language of their own care plans, completely dependent on staff. That dependence is not a footnote. It is the entire context for what it means to leave someone waiting an hour in a soiled brief.
Incontinence care is among the most basic obligations a nursing facility carries. Prolonged skin contact with urine and feces causes breakdown, pain, and infection. For residents who cannot reposition themselves, cannot call out effectively, or cannot physically summon help, the interval between soiling and changing is not a minor scheduling matter.
R9 said she waits an hour. She said it the way someone describes a routine, not an emergency, because for her it had become routine.
The inspection was conducted on September 29, 2025, following a complaint. CMS classified the harm level as minimal harm or potential for actual harm, affecting few residents. The deficiency was cited under F0677, which covers basic personal hygiene and activities of daily living.
R7's care plan included a note that he was known to allege he had been waiting for hours. On September 24, he told inspectors he had been in the same brief since 8:30 that morning. No one had checked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Abbington Vlge Nrsg & Rhb Ctr from 2025-09-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
Abbington Vlge Nrsg & Rhb Ctr in ROSELLE, IL was cited for violations during a health inspection on September 29, 2025.
That resident, identified in inspection records as R7, had hemiplegia and dementia.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.