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F0600
D

Failure to Provide Required Toileting Assistance Resulting in Resident Neglect

Butler, Pennsylvania Survey Completed on 07-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a history of dementia, left below-knee amputation, and anxiety, who required staff assistance for toileting due to an activity of daily living (ADL) self-care deficit, was not provided the necessary care. The resident's care plan and facility policy required assessment and provision of appropriate transfer and toileting assistance. Documentation by a nurse aide indicated the resident was incontinent and received toileting hygiene assistance in the morning. However, during an observation later that morning, the resident was found lying in bed with a soiled gown saturated in urine, soiled bed sheets, and a noticeable odor of urine present. Further review confirmed that the assigned nurse aide did not assist the resident with toileting as required, despite documentation stating otherwise. The aide acknowledged that the resident was saturated in urine and that the sheets needed to be changed. This failure to provide necessary toileting assistance and hygiene resulted in the resident being left in a soiled condition, constituting neglect as defined by the facility's policies and state regulations.

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