Failure to Document and Complete Ostomy Care as Ordered
Summary
The facility failed to ensure proper documentation and completion of ostomy care for a resident with an ostomy status diagnosis. The resident's care plan required staff to administer treatments as ordered, and a physician's order specified that ostomy care should be provided and liquid output recorded every shift. However, review of the treatment administration record for March 2025 revealed multiple instances where documentation of ostomy output was missing on both day and night shifts, and there was at least one instance where ostomy care was not completed as ordered. These omissions were identified during a review of the resident's clinical record and treatment administration records.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with an ileostomy did not receive timely colostomy care as required by physician orders and care plan. The resident was left covered in stool for hours after her colostomy bag burst, despite activating her call light for assistance. Family intervention and photographic evidence confirmed repeated failures by staff to empty, burp, or change the ostomy bag as needed, resulting in the resident remaining soiled for extended periods.
A resident with a colostomy did not have colostomy drainage bag changes completed or documented as ordered by the physician. The order to change the bag every three days and as needed was not properly entered into the treatment administration record, preventing staff from documenting care. Facility leadership confirmed the lack of documentation, and the resident reported incidents of the bag bursting.
A resident who was dependent on staff for personal hygiene did not consistently receive colostomy care as ordered or according to their preferences. Documentation showed multiple missed shifts where the colostomy pouch was not emptied, and staff interviews revealed that CNAs only emptied the pouch when directed by a nurse, often not cleaning it as the resident preferred. Observations confirmed the pouch was left full and not properly maintained, and the ADON could not verify that care was provided as required.
Two residents with colostomies did not consistently receive ostomy care as ordered by their physicians, as documented in the TAR and confirmed by the ADON. Both residents were cognitively intact and had care plans specifying the need for regular ostomy care, but records showed multiple missed care opportunities.
A facility failed to address a resident's leaking nephrostomy tube and did not document the resident's transfer to the ER for replacement. The resident, with multiple health issues, was found with a leaking collection bag wrapped in a towel and trash bag. The RN was unaware of the leak, and despite contacting urology, the NP ordered an ER visit. The DON confirmed the lack of documentation, violating facility policy.
A resident with a colostomy experienced inadequate care, resulting in frequent leaks and a rash due to improper appliance fitting and untimely pouch changes. Staff interviews and observations confirmed the issues, with the DON and Wound Nurse acknowledging the rash caused by gastric juices. The facility's policy on monitoring and addressing pouching problems was not adequately followed.
Failure to Provide Timely Colostomy Care
Penalty
Summary
A deficiency occurred when staff failed to provide timely colostomy care to a resident with a history of rectal cancer and an ileostomy. The resident had physician orders for staff to empty the ostomy every shift and as needed, and to change the appliance weekly and as needed. Despite these orders, the resident reported that her colostomy bag burst open and, after activating her call light, a nurse entered the room, turned off the call light, and left without providing care. The resident remained covered in stool for at least two hours, ultimately calling a family member for assistance. The family member arrived to find the resident still soiled, took photographs, and cleaned her up before reporting the incident to the unit manager. The family member stated that similar issues had continued to occur. Observations confirmed the resident's colostomy bag was often not emptied or changed in a timely manner, with the bag being half full of liquid stool during one interview and the resident found covered in stool during another observation. Photographic evidence provided by the family member showed dried, liquid stool on the resident's gown and bedding, and the colostomy bag not attached to the abdomen. The Interim DON acknowledged awareness of frequent leaks but was unaware of the lack of timely emptying. These findings demonstrate a failure by staff to provide appropriate and timely ostomy care as required by the resident's care plan and physician orders.
Failure to Document and Perform Colostomy Bag Changes per Physician Orders
Penalty
Summary
The facility failed to ensure that colostomy drainage bag changes were completed according to physician orders for a resident with a colostomy. The physician's order specified that the ostomy bag should be changed every three days and as needed. However, a review of the treatment administration record over a specified period revealed no documentation that these changes had been performed as ordered. The resident, who had diagnoses including surgical aftercare, colostomy status, pulmonary embolism, and malignant neoplasm of the colon, reported that her colostomy bag had burst a couple of times when she rolled over in bed, and she was unsure how often staff were changing the bag. Further investigation found that the order to change the colostomy bag appeared on the treatment administration record but was not entered correctly, preventing staff from documenting when the changes were completed. Interviews with facility leadership confirmed the lack of documentation for the required colostomy bag changes. Additionally, facility policy required staff to document the date and time of colostomy care, but this was not done in this case.
Failure to Provide Ordered and Preferred Colostomy Care
Penalty
Summary
The facility failed to provide colostomy care as ordered and according to the resident's preferences for one resident who was alert, oriented, and dependent on staff for personal hygiene. The resident had a physician's order to have the colostomy bag emptied every shift, with documentation of the procedure and any changes in stool. The care plan, reflecting the resident's preference, specified that the colostomy pouch should be emptied, rinsed well with water, and reapplied, or replaced if not clean. However, review of CNA documentation showed multiple instances where there was no evidence that the colostomy pouch was emptied on various shifts and days. Interviews with the resident confirmed that the pouch was not emptied or cleaned as required, leading to discomfort and nausea due to the buildup of gas and fecal matter. Further interviews with staff revealed that CNAs only emptied the colostomy pouch when instructed by a nurse and typically did not follow the resident's preference for cleaning the pouch. Observations confirmed that the resident's colostomy pouch was often left more than half full and puffed up with gas. The Assistant Director of Nursing verified the lack of documentation and could not confirm that the required care was provided. These findings demonstrate a failure to ensure that colostomy care was consistently provided as ordered and per the resident's stated preferences.
Failure to Provide Ordered Colostomy Care
Penalty
Summary
The facility failed to provide colostomy care as ordered for two residents who required such services. One resident, admitted with diagnoses including hypertension, pancreatic disorder, and a colostomy, had physician orders for colostomy care to be provided once per shift. Review of the Treatment Administration Records (TAR) showed that colostomy care was documented as completed on only 18 of 35 opportunities in February, 53 of 62 in March, and 24 of 30 in April. The resident's care plan also specified that the ostomy appliance should be changed as ordered. Another resident, admitted with diagnoses including cirrhosis of the liver, diabetes mellitus, diverticulitis, and a colostomy, had orders for ostomy care every shift. The TAR for April indicated that ostomy care was provided on 28 of 30 opportunities. Both residents were assessed as cognitively intact for daily decision-making. During an interview, the Assistant Director of Nursing confirmed that ostomy care was not completed as ordered for these residents.
Failure to Address and Document Nephrostomy Tube Leak
Penalty
Summary
The facility failed to timely address a resident's leaking nephrostomy tube and accurately document the resident's hospitalization and subsequent nephrostomy tube replacement. The resident, who was admitted with multiple diagnoses including atrial fibrillation, diabetes mellitus, and obstructive uropathy, was observed with a leaking nephrostomy collection bag wrapped in a towel and placed inside a trash bag. The registered nurse was unaware of the leak until it was pointed out, and the facility delayed contacting the urology office regarding the issue. Despite obtaining an appointment for the resident with urology, the nurse practitioner ordered the resident to be sent to the emergency room for replacement of the leaking nephrostomy collection bag. However, there was no documentation in the medical record of the resident being transferred to the ER or the nephrostomy tube being replaced. The Director of Nursing confirmed the lack of documentation, which was against the facility's policy that required timely and factual documentation of care services.
Inadequate Colostomy Care Leading to Rash and Leakage
Penalty
Summary
The facility failed to provide appropriate and adequate colostomy care for Resident #10, who had a colostomy due to malignant carcinoid of the stomach and other health issues. The resident's medical records indicated a need for specific colostomy care, including cleaning the colostomy with soap and water, applying skin prep, and changing the pouch when it was one-third to one-half full. However, interviews and observations revealed that the colostomy pouch was not always replaced timely, leading to leaks and a rash on the resident's abdomen. Interviews with staff, including an LPN and a CNA, confirmed that the colostomy pouch often leaked, and the resident frequently needed cleaning upon their arrival. The LPN expressed concerns about the night shift not emptying the pouch timely, and the CNA acknowledged the rash was not a new finding. Observations showed the colostomy appliance was not fitting properly, with the hole in the wafer cut too big, and paste was used unnecessarily, which contributed to the leakage and skin irritation. The Director of Nursing and the Wound Nurse confirmed the presence of a rash caused by gastric juices contacting the skin, and the DON noted the improper fit of the appliance due to the stoma's position. Despite the ongoing issue with the rash and leaking, there was a lack of documentation regarding the rash's recurrence. The facility's policy required monitoring the skin for breakdown and making appropriate referrals for ongoing pouching problems, which was not adequately followed, leading to the deficiency.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
