The woman, identified as Resident B, had finished her breakfast and was waiting for assistance to get into her chair when inspectors observed her on October 27 at 10:27 a.m. She told them staff had brought her breakfast tray and said they would be back to help her transfer out of bed.
They didn't return for 45 minutes.
When two certified nursing assistants finally entered her room at 11:12 a.m., they discovered the resident was incontinent of large amounts of urine. Her last incontinence care had been completed at 7:30 a.m., according to CNA 1.
The resident's brief was saturated. The lift sheet underneath her was soaked through to the bottom sheet. A large circle of wetness had formed on the bottom sheet itself.
CNA 1 acknowledged the saturated brief and the wetness of the sheets as they began morning care.
The resident's medical record revealed a troubling pattern. She had been diagnosed with metabolic encephalopathy, multiple urinary tract infections, and sepsis. A hospital physician's note from October 15 specifically documented her recurrent urinary tract infections.
Her care plan, last revised on September 2, stated she would be offered and provided assistance to the toilet as needed and requested. A September 4 assessment indicated she was always incontinent of bowel and bladder and required dependent care for toileting hygiene and transfers.
The facility had readmitted the resident just four days before the inspection. An October 23 assessment noted she was oriented to person, place, and time with no mental impairment, but was incontinent of bowel and bladder and unable to recognize the need to void.
Her baseline care plan specified the toilet would be offered upon rising, before and after meals, and before bedtime. Staff were supposed to check for incontinence and change her brief as needed.
When inspectors interviewed the Director of Nursing that afternoon, she revealed a significant gap in facility protocols. There was no policy for how often residents should be checked for incontinence, she said. If residents voided frequently, they should be checked more often. Generally, residents were checked before and after meals and before bedtime.
The nursing assistant curriculum used by Indiana's health department tells a different story. The state training materials specify that residents with incontinence should be monitored frequently for needed perineal care and brief changes.
For Resident B, who couldn't recognize when she needed to void and had a documented history of urinary tract infections, the nearly four-hour gap between incontinence checks represented exactly the kind of care failure the state curriculum aimed to prevent.
The resident's medical complexity made timely care even more critical. Her diagnoses of metabolic encephalopathy and sepsis, combined with her recurrent UTIs, created a clinical picture where prolonged exposure to urine could worsen existing infections or create new complications.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. But for Resident B, lying in her own urine while breakfast grew cold and promises of assistance went unfulfilled, the harm was immediate and personal.
The inspection found this pattern affected few residents overall. But the case highlighted a fundamental question about care standards: How long is too long for a vulnerable resident to wait for basic dignity?
The facility's own assessment acknowledged Resident B required maximum to dependent assistance for her daily care needs. She couldn't transfer herself, couldn't manage her own toileting, and couldn't recognize when she needed help.
She could, however, tell inspectors that staff had promised to return.
They eventually did, 45 minutes later than observed, nearly four hours after her last incontinence care. By then, the damage was done - to her dignity, her comfort, and potentially her health.
The federal citation requires Avalon Springs to develop a plan of correction to continue participating in Medicare and Medicaid programs. But for residents like Resident B, the question remains whether promises of timely care will translate into actual assistance when they need it most.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Springs Health Campus from 2025-10-27 including all violations, facility responses, and corrective action plans.