The incident occurred during the early morning hours of June 7, 2025, at Harrisonburg Health & Rehab Center. CNA #7 came into the room to provide care for Resident #8 but completely skipped changing Resident #5's brief before ending the shift.
When the day shift arrived at 8:00 a.m., CNA #6 found Resident #5 in a heavily soiled brief with wet bed linens. The condition indicated the resident had been left unchanged for hours.
The roommate's account proved damaging. Resident #8 told investigators that CNA #7 had entered their shared room during the final rounds of the night shift. The aide provided care for him but left without changing Resident #5's brief at all.
CNA #6 immediately reported the discovery to LPN #5. Both staff members provided written statements on June 7 describing finding Resident #5 in the heavily soiled condition with wet bedding.
The facility's director of nursing suspended CNA #7 immediately and sent a report to the state agency. Their investigation supported evidence that the aide had failed to provide timely incontinence care before the shift change.
Resident #5 required frequent brief changes due to incontinence from weakness and an enlarged prostate. The care plan, revised on June 23, specifically called for checking and changing briefs frequently as needed and providing hygiene with each brief change.
The plan also required one-person assistance with toileting and keeping the resident clean and dry. CNA #7 had ignored all of these requirements during the final care rounds.
A skin assessment conducted after the incident found no skin damage from the prolonged exposure to waste. But the potential for harm was significant given the resident's medical condition and need for frequent changes.
The roommate's testimony eliminated any doubt about what happened. Resident #8 had a clear view of the aide's actions and could confirm that CNA #7 deliberately chose to provide care for one resident while completely neglecting the other.
Both residents were no longer at the facility when federal inspectors arrived in September to investigate a complaint about the incident. The director of nursing provided details about the investigation during an interview on September 23.
The facility's own documentation showed a pattern of required care that CNA #7 had abandoned. Written statements from two staff members and the roommate's account created an undeniable record of neglect.
CNA #7's suspension came after the facility determined the aide had violated basic standards for resident dignity and safety. Leaving someone in soiled conditions overnight represents one of the most fundamental failures in nursing home care.
The incident occurred despite clear care plan requirements and facility policies designed to prevent exactly this type of neglect. The resident's incontinence was a known medical condition requiring specific interventions that the aide simply ignored.
Federal inspectors reviewed the case with the administrator, director of nursing, and regional nurse consultant during a meeting on September 23. No additional information was provided before the survey ended.
The roommate's witness account proved crucial in the facility's investigation. Without Resident #8's testimony, CNA #7 might have claimed the brief change occurred or blamed the soiled condition on something else.
Instead, the roommate provided clear evidence that the aide had been selective in providing care, helping one resident while completely abandoning the other. The deliberate nature of the neglect made the violation particularly serious.
The facility acted quickly once the neglect was discovered, suspending the aide and reporting to state authorities the same day. But the incident had already occurred, leaving Resident #5 in degrading conditions for hours.
Both residents have since left the facility, taking their firsthand knowledge of the incident with them. The investigation relied on staff statements and the facility's own documentation of what happened that morning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harrisonburg Hlth & Rehab Cntr from 2025-09-24 including all violations, facility responses, and corrective action plans.
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