F0558

G

Failure to Provide Timely Showers and Incontinence Care, Leaving Residents Soiled for Extended Periods

Morton, Illinois Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences for hygiene and incontinence care, resulting in residents going without weekly showers and remaining in urine and feces for extended periods. Facility policies state that residents have rights to exercise autonomy and choice in daily life and care, and that CNAs are responsible for bathing, grooming, answering call lights promptly, and washing and drying incontinent residents. The Incontinent Care policy requires incontinent residents to be checked approximately every two hours and provided perineal and genital care after each episode. Despite these policies, Resident Council minutes and concern/compliment forms over several months document repeated complaints that showers were a persistent concern on all shifts, that residents had to ask multiple times to receive showers, and that some residents received bed baths instead of preferred showers.

One cognitively intact resident who required partial/moderate assistance with toileting reported going to the bathroom, removing a wet disposable brief, and activating the bathroom call light for a replacement. After waiting 35 minutes without staff response, the resident put the wet brief back on and returned to the room to activate the room call light. The resident estimated wearing the wet brief from about 8:45 a.m. until 10:30 a.m., describing discomfort, burning, and feelings of helplessness and anger due to not being properly cared for. Another cognitively intact resident, dependent for toileting and rolling, reported that after receiving a laxative and having a bowel movement, staff did not respond promptly to the call light, resulting in remaining soiled for more than 90 minutes, and that bed linens were not changed afterward. This resident stated feeling degraded and that dignity was compromised, and also reported being given a quick bed bath instead of a requested shower because use of a mechanical lift required two staff. The same resident described waiting two and a half hours to be changed when an agency CNA said she had a hernia and could not lift, requiring the resident to wait for the next shift.

Another resident with moderate cognitive impairment and partial/moderate assistance needs for toileting and transfers was reported by a roommate to have been left wet in urine for over 40 minutes after a call light was activated at 6:14 a.m. and not answered until 6:56 a.m. A cognitively intact resident who was always incontinent of urine and had an ostomy, and who was dependent for toileting and showers, stated that a family member typically visited daily to assist with showers, disposable brief changes, and ostomy care, and that staff relied on this family member to perform these tasks. When the family member did not visit, staff attempted to provide bed baths instead of showers, and the resident had to repeatedly request the scheduled shower. Another cognitively intact resident, dependent on toileting care and requiring substantial/maximal assistance for rolling, reported waiting all morning and afternoon for help changing a soiled and wet disposable brief. A staff member began to assist but left, stating there were no clean sheets and did not return, leaving the resident with soiled brief and linens. The resident became visibly upset, tearful, and angry, questioning whether life would continue with such mistreatment.

A CNA who worked on the day the last resident described the incident stated that it was after 3:00 p.m. when the resident reported having asked all day to be changed, and that the resident was covered in urine from back to neck and down to the feet, with a saturated brief, strong urine odor, and reddened skin everywhere urine had touched. Another CNA stated that all staff were having to choose which resident cares to complete and that agency staff often arrived hours late, slowing resident care. A different CNA reported that staffing was becoming an issue, that the facility had not evaluated resident load compared to staff, and that CNAs were required to perform dietary tasks such as serving and picking up room trays, serving in the dining room, and feeding residents while also trying to chart and provide resident care, resulting in residents suffering because CNAs could not care for them properly. The Administrator acknowledged being unaware that residents were sitting in urine and feces for long periods, confirmed CNAs were required to help with dietary tasks, and agreed staff were overworked. The Ombudsman reported receiving a call from a very upset resident who said she had sat in feces for 90 minutes with the call light on and no staff response, and also noted numerous complaints from residents about call lights not being answered or being turned off by staff who said they would return but did not.