MercyOne Centerville: Patient Left in Feces 4 Hours - IA
Staff B, an LPN working the morning shift on August 21, discovered the situation when she entered Resident #15's room and found dried feces stained to his skin and linens. The patient complained he had been lying in the waste for four hours without anyone checking on him.
"Some of the feces had dried to the resident's skin and stained the linens," Staff B reported to inspectors. The appearance and condition matched the resident's complaint about how long he had been left unattended.
The breakdown occurred during a chaotic overnight shift when the Director of Nursing worked alongside Staff E, an LPN, from 2:00 AM to 6:00 AM on August 21. Both nurses assumed the other had checked on Resident #15, leaving him without incontinence care during the busy pre-dawn hours.
Staff E told inspectors that night shift staff were "extremely busy from 3:00 AM until the end of their shift at 6:00 AM." Residents typically started waking around 3:00 AM needing bathroom assistance or brief changes, while early risers required help getting up for the day.
The facility's policy requires staff to check on residents every two to three hours during night shifts. For patients who are "totally incontinent," staff must check and change them during these rounds if needed.
Resident #15 usually turned on his call light when he needed to be changed, but sometimes required staff to wake him up. Staff E noted the patient had episodes of confusion and would be "more out of it at times."
On the night in question, Staff E was helping another resident when she assumed the Director of Nursing had checked on Resident #15. The DON left early once the morning LPNs arrived, unaware that Resident #15 had been missed during rounds.
Staff E only learned about the oversight when Staff B emerged from Resident #15's room carrying soiled linens and reporting the patient's complaint. "Staff E reported she thought that the DON had checked on Resident #15, as she had been helping another resident," according to the inspection report.
The Director of Nursing initially told inspectors on August 26 that she was "unaware of a complaint voiced by Resident #15 of not getting his incontinence care done timely." She confirmed working the overnight shift and explained that staff typically coordinate care by talking back and forth about which residents they had attended to.
The DON described the facility's approach to bundling care, explaining that staff would try to combine the resident's CPAP machine adjustments with incontinence care. Resident #15 frequently removed and reapplied his continuous positive airway pressure device throughout the night.
Staff B characterized Resident #15 as requiring assistance from one staff member for personal and toileting hygiene. The facility's December 2024 policy states that staff "would provide whatever care was needed for each resident based on their assessment and care plan."
The nursing schedule for August 2025 showed Staff B working three consecutive days starting at 6:00 AM, while Staff E worked the corresponding night shifts from 6:00 PM to 6:00 AM. The DON's unusual overnight shift on August 21 disrupted the regular staffing pattern.
Federal inspectors found the facility failed to ensure residents received necessary care and services to maintain good hygiene. The violation affected few residents but created potential for actual harm.
The breakdown in communication between the DON and Staff E left Resident #15 lying in waste that dried and adhered to his skin. By morning, the soiled conditions required removing stained linens along with cleaning the resident's body.
Staff E's assumption that the DON had provided care, combined with the DON's early departure, created a gap in the facility's two-hour checking system. The resident's complaint and the physical evidence confirmed he had been neglected for an extended period during the vulnerable overnight hours.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mercyone Centerville Medical Center from 2025-08-28 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
MercyOne Centerville Medical Center in Centerville,, IA was cited for violations during a health inspection on August 28, 2025.
The patient complained he had been lying in the waste for four hours without anyone checking on him.
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.