Failure to Provide Timely Incontinence Care and Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living, specifically toileting and incontinence care, for a resident who was unable to perform these tasks independently. On 1/20/26 at 11:00 a.m., Resident #6 was heard calling out from outside their room, requesting to be changed, while two nurses, including the resident’s assigned nurse (Staff #4), were observed standing outside the room. Staff #4 responded to the resident by stating that the resident had just put on the call bell and to give staff a chance to get there, but the resident continued to call out for help. A strong odor of urine was noted coming from the resident’s room at that time. During an interview conducted at the time of the observation, Resident #6 reported not being changed in a timely manner and stated that the last time they had been changed was in the middle of the night, and that as of 11:00 a.m. they had not yet been changed. In a follow-up interview at 1:00 p.m., the resident reported that they were changed about one hour after the initial observation, around 12:00 noon. The Director of Nursing was informed of the observation and responded, “ok.” This deficiency was identified for 1 of 1 residents reviewed for assistance with activities of daily living and toileting/incontinence care.
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