Duncanville Healthcare: Resident Left Wet 5+ Hours - TX
The woman, identified in inspection records only as Resident 2, is totally dependent on staff for toileting. Her care plan says so. Her quarterly assessment says so. Everyone at the facility, when inspectors interviewed them that afternoon, agreed that incontinence checks were supposed to happen every two hours.
They did not happen.
The certified nursing assistant assigned to Resident 2 told inspectors the last time she had changed the resident was before breakfast, which the facility's own posted meal schedule shows began at 7 a.m. for hall trays. By the time inspectors spoke with the CNA at 1:20 p.m., more than five hours had passed. The CNA said she had spent the morning giving other residents bed baths and getting them up. "She didn't get around to changing Resident 2 again," the inspection report states.
The CNA knew what that meant. She told inspectors directly that delayed incontinence care placed residents at risk for skin breakdown.
When inspectors spoke with Resident 2 herself at 2:45 p.m., through an account manager who translated, the woman said she was unsure but thought she had not been changed that day and that no one had asked whether she needed to be.
The charge nurse, interviewed at 2:23 p.m., described the system clearly: charge nurses were responsible for rounding every two hours specifically to verify residents had received incontinence care. The nurse would go directly to the patient to check. That was the expectation. She told inspectors she had been busy and had not checked Resident 2 that day.
The Director of Nursing, interviewed at 4:10 p.m., confirmed the same standard and listed what goes wrong when it isn't met: infection, skin breakdown, dignity issues, and pain from sitting.
Resident 2 is elderly, has dementia, has lost significant muscle mass, and has been diagnosed with protein-calorie malnutrition and Type 2 diabetes. Diabetic patients face elevated risk of skin breakdown and infection. She cannot complete a cognitive interview. She cannot remind staff she needs care. She depends entirely on the people around her to notice and respond.
On this morning, nobody did.
The violation was cited at the minimal harm level, meaning inspectors determined no actual skin breakdown or infection had been documented as a result. But the federal standard inspectors cited covers more than physical injury. It covers the maintenance of dignity. It covers what it means to leave a person who cannot advocate for herself sitting in soiled clothing for most of a morning while staff moved through their other tasks.
The facility's own ADL policy, revised in March 2018, states that appropriate care and services will be provided for residents who cannot carry out activities of daily living independently, including assistance with elimination. The policy existed. The care plan existed. The two-hour rounding expectation existed. None of it reached Resident 2 that morning.
What reached her, eventually, was a federal inspector asking whether anyone had changed her that day. She wasn't sure, she said. She thought probably not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Duncanville Healthcare and Rehabilitation Center from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
Duncanville Healthcare and Rehabilitation Center in Duncanville, TX was cited for violations during a health inspection on April 30, 2026.
The woman, identified in inspection records only as Resident 2, is totally dependent on staff for toileting.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.