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F0600
D

Failure to Provide Incontinence Care Resulting in Resident Neglect

Indianapolis, Indiana Survey Completed on 12-22-2025

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 dependent resident with a history of cerebral infarction, dementia, and type 2 diabetes mellitus was not provided incontinence care during an entire eight-hour shift. The resident was totally dependent on staff for toileting and hygiene, requiring a stand lift and assistance from two staff members. According to the care plan, peri-care was to be completed with each incontinence episode. However, documentation and interviews revealed that the assigned CNA did not provide or document any toileting or incontinence care for the resident during the shift. When the resident's daughter visited, she found the resident sitting in a recliner with a strong odor of urine and feces, and both the resident's clothing and recliner were saturated. The incontinence brief was so saturated it fell to the resident's knees when she was assisted to stand. The facility's point of care documentation confirmed that no toileting or incontinence care was recorded for the resident during the CNA's shift. The CNA later admitted to neglecting her duties during this period. The facility's policies and the CNA's job description required regular checks, assistance with toileting and incontinence needs, and proper documentation of care provided. These requirements were not met, resulting in the resident being left in soiled clothing and furniture for an extended period.

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