Resident #31's husband discovered her still on the bedpan when he returned for a visit on July 13, after leaving her there at 2:00 PM. The woman, who has dementia and chronic pain along with nerve damage affecting her bladder and bowel control, had developed a red ring around her buttocks from sitting on the bedpan.
"I was afraid when I felt alone," the resident told inspectors during their September interview.
The facility's own progress notes revealed the breakdown that led to the prolonged ordeal. Certified nursing aides failed to give each other proper report during the 2:00 PM shift change, leaving the incoming CNA unaware that Resident #31 had been placed on a bedpan.
The resident's care plan shows she requires total assistance with toileting and hygiene due to her medical conditions. She has a suprapubic catheter and neurogenic bowel, meaning nerve damage has disrupted normal bladder and bowel function.
This wasn't an isolated incident. The resident and her spouse told inspectors she had been left on bedpans for hours at least twice before — once on May 9 and again on July 13. During the May incident, she was also wearing the same clothes from the previous day when her husband arrived.
Staff A, a certified nursing aide, acknowledged to inspectors that Resident #31 "complained every time" staff put her on the bed pan. The aide said the facility started using a timer on the resident's door after the July incident.
But problems persisted. The resident's husband found the call light out of reach again during his visit on September 28, just one day before inspectors interviewed the couple.
The Director of Nursing confirmed she knew about the facility's history of bedpan concerns with this resident. She told inspectors there was a recent issue with some staff using timers on their phones instead of the door timer, which concerned the resident's spouse.
Federal regulations require nursing homes to treat residents with dignity and provide care that maintains or enhances quality of life. The facility's own admission packet, revised in August 2022, states that residents have a right to dignified existence and self-determination.
The July 13 progress note shows a nurse assessed the resident after she was finally removed from the bedpan and found her skin was intact without bruising, though the red ring was visible. The note documented that the incoming CNA was educated about her responsibility to check residents every two hours and when coming on duty.
Resident #31's medical conditions make proper toileting assistance critical to her health and dignity. Her Minimum Data Set assessment from July shows she cannot transfer to a toilet due to her medical condition and safety concerns, making her completely dependent on staff for hygiene needs.
The inspection found the facility failed to ensure dignified care, citing minimal harm with few residents affected. Hallmar Village reported a census of 44 residents at the time of the October inspection.
The resident's fear of being alone, combined with call lights placed beyond her reach, illustrates how basic communication failures can compound into dignity violations. Her husband's repeated discoveries of inadequate care suggest systemic problems with staff communication and resident monitoring.
Despite the facility's attempts to implement door timers after the July incident, the September call light problem shows the underlying issues with staff awareness and accountability remained unresolved. The resident continues to depend entirely on others for her most basic needs, left vulnerable when those systems fail.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hallmar Village from 2025-10-02 including all violations, facility responses, and corrective action plans.