The resident, identified as Resident #30 in federal inspection records, had rung her call light at 9:20 AM on October 18th when she needed help getting to the toilet. Staff didn't arrive until sometime after 9:45 AM. By then, she had been incontinent of bowel in her bed.
"It is bad enough to have to need help, but to be in that situation was horrible," the resident told federal inspectors on November 24th. She described feeling "humiliated" by the incident.
The resident scored a perfect 15 out of 15 on cognitive testing, indicating she was mentally intact and fully aware of what was happening to her during the prolonged wait for assistance.
Federal records show the 66-year-old woman was admitted in early October following a periprosthetic fracture around her right knee prosthetic. She also suffered from muscle weakness after a slip-and-fall accident. Her medical conditions included morbid obesity, depression, chronic pain syndrome, and lower back pain.
Due to her injuries and conditions, she required substantial or maximal assistance for toileting, bathing, putting on footwear, and transferring from bed to chair. She was completely dependent on staff for lower body dressing and used a wheelchair for mobility.
The facility had identified her as being at risk for skin breakdown due to decreased mobility and incontinence. Her care plan, dated October 14th, specifically called for staff to assist with incontinence care using soap and water and to help with toileting as needed.
But when she actually needed that help, nobody came.
The incident came to light during a complaint investigation by federal inspectors on November 25th. The complaint, numbered 2649219, focused on staff responsiveness to resident call lights.
During the same inspection, investigators found additional problems with basic resident care documentation. The Director of Nursing confirmed that skin assessments were supposed to be completed during resident showers, but shower sheets for another resident showed assessments were documented on only two dates - November 9th and November 12th. Other shower forms contained no skin assessment information at all.
This pattern of incomplete documentation raises questions about whether staff are actually performing the care they're required to provide, or simply failing to document it properly.
For Resident #30, the failure wasn't about documentation. It was about 25 minutes of waiting in an increasingly desperate situation, followed by the shame and discomfort of sitting in her own waste until someone finally answered her call.
The resident's account provides a window into daily life for nursing home residents who depend entirely on staff for basic human needs. When that system fails, the consequences are immediate and deeply personal.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" and affecting "some" residents. But for the woman who lived through those 25 minutes, the harm was neither minimal nor potential.
She had rung her call light because she needed help. She was cognitively intact, aware of her body's needs, and followed the proper procedure for requesting assistance. The system simply didn't work.
The inspection occurred more than a month after the October incident, suggesting the resident's complaint prompted the federal investigation. Her willingness to report what happened to her may have prevented similar incidents for other residents who depend on staff to answer their calls for help.
Country Club Retirement Center IV operates at 55801 Conno-Mara Drive in Bellaire, a small Ohio River town near the West Virginia border. The facility's failure to respond to call lights represents one of the most basic breakdowns in nursing home care - the inability to help residents with essential human needs when they ask for help.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Club Retirement Ctr IV from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
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