Riverside Lifelong: Resident Left in Soiled Brief - VA
The resident told inspectors on August 19 that she knows when she needs to use the toilet but "most of the time, she was unable to get the staff to respond in time for her to utilize the toilet." Staff encouraged her to wear an incontinence brief "in case she had another accident."
She frequently soiled herself because nurses couldn't locate the Stedy lift required to transfer her, or because no second nurse was available to assist, according to the inspection report from August 25.
The woman had been admitted to the facility after an acute care hospital stay following spinal fusion surgery on vertebrae L2 through L5. She also had blood clots in her left arm. Her mobility assessment showed she was dependent on staff for standing and transferring but had no cognitive impairment that would prevent her from knowing when she needed the bathroom.
A note on the whiteboard in her room stated she required two people to assist with transfers using the Stedy lift.
The resident told inspectors she was constipated but currently experiencing diarrhea. She said she had awakened that morning covered in waste. Despite being continent and aware of her bodily functions, she was wearing an incontinence brief because staff couldn't respond quickly enough to her requests for help.
"She will need to be able to toilet herself before returning home, as she will not have anyone to assist her," the resident told inspectors, explaining the importance of maintaining her toileting abilities during rehabilitation.
Two days later, on August 21, the woman told inspectors "the toileting concerns had not changed, and she was still wearing incontinence briefs."
The interim Rehabilitation Director told inspectors that the rehabilitation team communicated the resident's transfer abilities to nursing staff by writing instructions on the whiteboard in her room. But the system apparently wasn't working.
When inspectors presented their findings to facility leadership on August 25, the Administrator said there were sufficient Stedy lifts in the facility, with each unit having one to two lifts available. The Administrator also questioned why the instructions specified two people were needed to operate the lift, saying two people weren't required and promising to follow up on the reason for that requirement.
The facility's failure violated federal regulations requiring appropriate care for residents who are continent or incontinent of bowel and bladder functions.
The woman's case illustrates how equipment shortages and staffing issues can force continent residents into incontinence, potentially undermining their rehabilitation goals and dignity. For someone recovering from major spinal surgery who needed to regain independence before returning home, being left to soil herself represented a significant setback in her care plan.
Federal inspectors classified the violation as causing minimal harm with the potential for actual harm, affecting few residents during their survey of the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverside Lifelong H & R Warwick Forest from 2025-08-25 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 20, 2026 · Our methodology
RIVERSIDE LIFELONG H & R WARWICK FOREST in NEWPORT NEWS, VA was cited for violations during a health inspection on August 25, 2025.
The woman had been admitted to the facility after an acute care hospital stay following spinal fusion surgery on vertebrae L2 through L5.
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.