Federal inspectors responding to a complaint found Resident #44 at Avon Place Healthcare Center in distress on the morning of October 22. The man told inspectors no staff members had entered his room throughout the night, and no one had attempted to turn and reposition him despite his high risk for developing additional pressure ulcers.
"He had an incontinence episode of bowel and could not call for assistance," inspectors wrote after interviewing the resident, who was found lying in bed crying at 8:33 a.m.
The 73-bed facility admitted the resident in January with multiple diagnoses including multiple sclerosis, muscle weakness, and severe protein calorie malnutrition. By September, his care plan documented pressure ulcers on his tailbone, both sides of his buttocks, and both heels.
His most recent assessment revealed he had one stage three pressure ulcer and two stage four pressure ulcers — the most severe category, indicating tissue death that extends through skin and fat into underlying muscle.
Multiple risk assessments throughout the year classified him as "very high risk" for developing additional pressure ulcers, dropping to merely "high risk" by his most recent evaluation. The resident required substantial or maximal assistance to roll from side to side and was completely dependent for toileting and personal hygiene.
When inspectors arrived that morning, they observed his call light hanging on his tube feeding pole, well beyond his reach. A certified nursing assistant confirmed both that the call light was inaccessible and that the resident had been incontinent and unable to summon help.
The nursing assistant could not report when the resident had last received care.
Resident #44 maintained intact cognition throughout his ordeal, meaning he was fully aware of his situation but powerless to remedy it. The facility's own policy, last revised in March 2021, required staff to ensure call lights remain "within reach per resident preference" when residents are in bed or confined to chairs.
The resident's care plan specifically called for assistance with positioning as needed — a critical intervention for someone at very high risk for pressure ulcers. Pressure ulcers develop when sustained pressure cuts off blood flow to tissue, and regular repositioning prevents the prolonged pressure that causes tissue death.
Stage four pressure ulcers like those documented on Resident #44 represent full-thickness tissue loss extending into muscle, tendon, or bone. These wounds can take months to heal and significantly increase risks of life-threatening infections.
The facility admitted him nearly ten months earlier, suggesting his condition had deteriorated substantially during his stay. His January skin risk assessment found him at very high risk, the same classification that persisted through March.
The last staff member to enter his room had been the nurse who hung his tube feeding, according to the resident's account to inspectors. The feeding tube indicated additional medical complexity requiring regular monitoring and care.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, though they found the facility failed to ensure basic access to assistance for a medically vulnerable resident. The inspection occurred in response to a complaint filed with state regulators.
Avon Place Healthcare Center operates under facility policies that acknowledge the critical importance of accessible call systems. The March 2021 policy explicitly requires staff to position call lights within residents' reach based on their individual preferences and limitations.
The violation affected one of three residents inspectors reviewed for call light accessibility during their October 23 investigation. The specific complaint that triggered the inspection was numbered 2643404 in state records.
Resident #44's situation illustrated how a seemingly minor oversight — a call light placed out of reach — can leave medically fragile residents in prolonged distress. His inability to summon help meant he remained in soiled conditions throughout the night while dealing with multiple serious pressure ulcers and the underlying conditions that made repositioning essential for his care.
The resident's tears when inspectors found him reflected not just physical discomfort but the helplessness of being unable to access the most basic tool for requesting assistance in a healthcare setting designed to provide round-the-clock care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avon Place Healthcare Center from 2025-10-23 including all violations, facility responses, and corrective action plans.