Resident #123 remained soaked from 10:00 AM until 1:40 PM on August 29, according to a September complaint inspection. Her mattress had developed a permanent divot directly under her body that wouldn't spring back when she rolled to her side.
"I'm uncomfortable and need to have my brief changed as I am wet head to toe," the woman told inspectors during their 1:40 PM visit. The cognitively intact resident scored a perfect 15 out of 15 on mental status testing, meaning she understood exactly what was happening to her.
The woman's white socks had turned brown with dried stains. Her body and bedding reeked of urine, and the smell had spread throughout her room and the entire unit, inspectors noted.
She told federal surveyors that inadequate staffing caused these incidents regularly. "There just were not enough staff to take care of residents, and this situation happened to her often," the inspection report states.
The facility's own records showed the woman required total assistance from one staff member for all daily living activities. Documents indicated she received a bath every morning, yet inspectors found her lying in filth for hours during daytime observation.
Inspectors never saw the woman out of bed during daylight hours throughout their entire survey.
The woman had been admitted with multiple serious conditions including Parkinson's disease, muscle atrophy, Type 2 diabetes, hypertension, and anemia. Despite her physical limitations, she served as her own responsible party and retained full decision-making capacity.
Federal surveyors observed similar hygiene failures affecting other residents during their visit. Multiple patients were found "soiled with dirty linens and clothing" and weren't receiving baths or basic cleanliness care on schedule.
On August 29, inspectors confronted facility leadership about the widespread problems during an end-of-day meeting. The administrator, director of nursing, and corporate clinical support consultant were informed that residents weren't being bathed properly or given hygiene care when needed.
The facility waited until September 3, the day before surveyors completed their inspection, to address the woman's care. The director of nursing told inspectors that Resident #123 was "now receiving needed care every 2 hours" and offered no additional information.
The inspection cited Parham Health Care for failing to provide activities of daily living care to dependent residents, affecting what federal regulators classified as "few" residents overall. The violation carried a designation of "minimal harm or potential for actual harm."
The facility's response came only after federal documentation of the neglect. For the Parkinson's patient, the damage had already been done. Her mattress bore permanent evidence of the facility's failure to provide basic human dignity, while she articulated her discomfort to strangers because staff wouldn't listen.
The woman's experience illustrates how understaffing claims become excuses for leaving vulnerable people in their own waste. Her cognitive clarity made the neglect particularly cruel – she knew she needed help, could ask for it, and understood why it wasn't coming.
Parham Health Care & Rehab Center operates at 2400 E Parham Road in Richmond. The September inspection was conducted in response to complaints about care quality at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parham Health Care & Rehab Center from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Parham Health Care & Rehab Center
- Browse all VA nursing home inspections