Failure to Provide Needed Toileting Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide needed assistance with toileting and ADLs for a resident with hemiplegia/hemiparesis and moderate cognitive impairment. The resident’s MDS dated October 2, 2025 documented a BIMS score of 11, indicating moderately impaired cognition, and Section GG showed the resident required supervision or touching assistance for toileting hygiene. The same MDS indicated the resident was frequently incontinent of both bladder and bowel. The care plan, initiated July 18, 2024, identified incontinence of bowel and bladder related to impaired mobility and documented that the resident required assistance with ADLs, with an intervention to provide assistance as required for completion of ADL tasks. On December 29, 2025, at 11:44 AM, surveyors observed the resident in his room, sitting on his bed in street clothes, with a strong odor of urine coming from the room. The DON, who was present during the observation, confirmed the strong urine odor. The DON also stated that the resident tries to go to the bathroom independently but sometimes does not make it in time. These observations and statements showed that, despite the documented need for assistance with toileting and ADLs, the resident was not consistently receiving the necessary help, resulting in episodes of incontinence and a strong urine odor in the room.
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