Federal inspectors found that nursing assistants repeatedly witnessed delays in colostomy care during a November complaint investigation. The facility's own policies require nurses to handle all colostomy bag changes, emptying, and burping — but staff told inspectors those changes often didn't happen promptly.
CNA A told inspectors that Resident #1 was "the only resident that had a hard time getting his colostomy bag changed." She could tell the nurse about the need, "and it could take an entire shift for the nurse to change Resident #1 colostomy bag."
The consequences were immediate and humiliating. If the bag wasn't changed, CNA A explained, "it could cause resident distress, there was the potential for it to leak on to the skin and cause breakdown and the dignity of the resident." Without proper emptying or changing, "the colostomy bag can have a blowout."
CNA B confirmed the pattern during her interview with inspectors. She had "witnessed the nurse take all shift before they would change the bag out" after residents requested changes. The delays created a cascade of problems: "the bag would lift and leak onto the resident, which was a dignity issue and could have led to possible skin irritation or breakdown."
On the day of inspection, LVN C admitted she hadn't changed Resident #1's colostomy bag despite his request before 11 a.m. Instead, she had only "burped" the bag and planned to change it after lunch. She asked the resident if he wanted to wait until after lunch, and he agreed.
LVN C defended the delay by saying the bag "was not full so no risk to Resident #1 if bag was not changed." But she acknowledged that "residents have the right to have their bag changed upon request."
The facility's leadership understood the stakes. Director of Nursing told inspectors she expected nurses to "burp/empty/change colostomy bags as soon as they are able once a resident request." She identified the harm clearly: "dignity issues at the least and to prevent bag from leaking on the skin which could be causative to the resident's skin and there is potential for infection."
The administrator echoed this expectation during his interview. "The resident has the right to have his or her colotomy bag emptied changed at any time it was their right," he told inspectors. He stated his expectation was "for staff to change upon request as soon as possible."
The administrator recognized that delays caused "resident dignity issues and prevent leaking on the skin."
Inspectors found the facility's own documentation supported residents' rights to prompt care. A facility document titled "Rights of the Elderly" from 2018 stated that elderly individuals have "the right to make the individual's own choices regarding the individual's personal affairs, care, benefits and services."
The inspection revealed a troubling disconnect between policy and practice. While facility leadership articulated clear expectations about prompt colostomy care and recognized the dignity and health risks of delays, multiple staff members described a routine pattern of residents waiting entire shifts for basic care.
CNAs, who work most closely with residents, were prohibited from providing the care residents needed. They could only alert nurses, then watch residents wait hours for attention to intimate bodily functions.
The inspection found that only nurses could handle colostomy bags, creating a bottleneck when nursing staff were busy with other duties. But the facility's own policies and leadership statements made clear that resident requests should be honored promptly.
When inspectors asked for the facility's colostomy care policy from the Director of Nursing, it was not provided before they completed their investigation.
The violation affected few residents but created minimal harm or potential for actual harm, according to the inspection classification. However, the testimony from multiple staff members suggested the delays were routine rather than isolated incidents.
Resident #1's experience illustrated how system failures in nursing homes can strip away dignity while creating medical risks. A simple request for basic hygiene care became an hours-long ordeal, with the resident forced to negotiate timing for his own bodily functions.
The inspection captured a moment when a resident had already been waiting since before 11 a.m. for a colostomy bag change, with the nurse suggesting he wait even longer until after lunch. That resident agreed to the delay, but only after being asked to accommodate the facility's schedule rather than having his immediate needs met.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Duncanville Healthcare and Rehabilitation Center from 2025-11-08 including all violations, facility responses, and corrective action plans.
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