Resident #25 had a bowel movement early on the morning of October 20, 2025, and activated her call light around 8:00 A.M. When Certified Nursing Assistant #819 responded, she told the resident "she would be right back in a few" and turned off the call light. She never returned.
Federal inspectors found the woman still waiting at 9:55 A.M., nearly two hours after calling for help. Her bed linens were visibly soiled with what inspectors described as an "extra-large bowel movement."
The resident told inspectors she had not been checked or changed since the night shift ended at 7:00 A.M. She remained in the soiled conditions until 11:12 A.M., when two nursing assistants finally provided care — more than three hours after her initial request.
The extent of soiling was severe. Inspectors documented feces down the woman's thighs, in her skin creases, and around her indwelling catheter. She required complete bed linen changes and full perineal cleansing.
Resident #25 cannot wear adult diapers because they irritate her skin, making timely staff response critical for her hygiene and health. Her medical conditions include morbid obesity, chronic kidney disease, lymphedema, and urinary retention. She is completely dependent on two staff members for toileting and bed mobility.
Her care plan specifically required staff to check and change her every two to three hours and as needed for incontinence. The plan also mandated keeping her skin clean and dry due to impaired skin integrity on her right lateral thigh caused by being bedfast.
When confronted by inspectors, CNA #819 admitted she knew the resident had a bowel movement and needed changing when she started her 7:00 A.M. shift. She explained she "had to assist other residents before she provided incontinence care to Resident #25."
The nursing assistant had been aware of the situation for over four hours before finally providing care. During that time, the resident lay in increasingly unsanitary conditions that violated her specific care requirements.
The facility's failure occurred despite having 69 residents and adequate staffing to meet basic hygiene needs. Resident #25 was cognitively intact and fully aware of her prolonged wait for assistance.
Federal regulations require nursing homes to provide necessary care and assistance for activities of daily living, including incontinence care, to residents who cannot perform these tasks independently. The delayed response violated these requirements and the facility's own care plan.
Inspectors classified the violation as causing minimal harm or potential for actual harm. However, leaving an immobile resident in fecal matter for hours creates risks for skin breakdown, infection, and dignity violations.
The incident emerged during a complaint investigation at the 69-bed facility. Hudson Springs Nursing and Rehab is disputing the citation, though staff members confirmed the timeline and delayed care during interviews.
Resident #25's experience illustrates the consequences when staff prioritize other tasks over basic hygiene needs for the most vulnerable residents. Her care plan explicitly recognized her total dependence on staff and her skin integrity risks, making the delayed response particularly concerning.
The woman's morning began with a reasonable request for basic care after a bowel movement. It ended with her lying in feces while staff attended to other duties, despite knowing her immediate need for assistance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hudson Springs Nursing and Rehab from 2025-10-23 including all violations, facility responses, and corrective action plans.
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