The resident told inspectors she was last changed at 1:30 AM on October 14. When she woke up between 5:30 and 6:00 AM, she felt cold wet sheets against her leg. Staff didn't change her again until 10:30 AM.
She ate breakfast in her wet brief.
The resident said staff "usually changed her two to three times during the night because she urinated frequently." On October 14, they changed her once.
NA #8, assigned to care for the resident during the night shift, admitted she never returned after the 1:30 AM change. She told inspectors by phone that "it had been a busy night" and she planned to change the resident around 6:00 AM, but found her shaking and asking for a nurse because her blood sugar was low.
The nursing assistant said she intended to return between 6:30 and 6:45 AM to change the resident, but her coworker had left shift early. She couldn't find anyone to help lift the resident, so she reported to the day shift that the resident needed changing.
She never asked the nurse for help.
"It was difficult when there were only 2 NAs working to get both NAs in one room to change the resident," NA #8 told inspectors. She acknowledged the resident "should have been changed one additional time during the night" and said she "probably should have asked" the nurse for assistance.
Two nursing assistants not assigned to the resident's care finally changed her at 10:30 AM. NA #5 and NA #6 had been asked by the unit manager to lift the resident into her wheelchair. When they entered her room, they found her "wet through her brief and turn sheet and onto her bed sheet."
They provided incontinence care before transferring her to the wheelchair.
NA #7, the day shift nursing assistant assigned to the resident, said she was "working her way towards" the resident but hadn't reached her before the other assistants changed her. The resident told NA #7 directly that she hadn't been changed since 1:30 AM and "should have been changed twice more during the night shift."
NA #7 was waiting for another nursing assistant to help her when the unit manager pulled someone from the rehabilitation floor to assist with the resident's care.
Nobody had told NA #7 during shift report that the resident had gone unchanged all night.
Unit Manager #1 said she was unaware the resident had gone nine hours without incontinence care. No one had asked her for help, though she said she "assisted with care to residents all the time."
She explained that NA #7 was an agency worker and "probably was waiting until one of the other NAs was free to assist."
The unit manager said facility policy required staff to round on residents every two to three hours and change them as needed. "No resident should go from 1:30 AM to 10:30 AM without being checked and changed several times," she told inspectors.
The resident's medical condition made the prolonged exposure to urine particularly concerning. When NA #8 found her shaking at 6:00 AM, the resident said she thought her blood sugar was low and asked for the nurse. The resident was more focused on eating breakfast than her wet brief because her blood sugar had been low earlier.
The inspection revealed a breakdown in basic care coordination. The night shift nursing assistant acknowledged she should have changed the resident but cited understaffing. The day shift assistant was waiting for help that never came. The unit manager remained unaware of the situation despite being available to assist.
The resident endured nearly four hours of lying in cold, wet sheets before breakfast arrived. She then ate her meal while still soaking in urine, prioritizing her diabetic care over her dignity and comfort.
Federal inspectors classified the violation as causing minimal harm to few residents, but the incident exposed systemic problems with staffing, communication, and basic hygiene protocols at the 28054 facility.
The Director of Nursing was not available for interview.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gastonia Health & Rehab Center from 2025-10-23 including all violations, facility responses, and corrective action plans.
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