F0557

D

Resident Left in Soiled Clothing for Extended Period, Violating Dignity

Longview, Texas Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a resident’s dignity by allowing him to remain in soiled clothing for an extended period and to be taken toward the dining hall without timely changing his clothes. The resident was an elderly male with unspecified dementia, epilepsy, schizophrenia, major depressive disorder, and cerebrovascular disease. His MDS showed a BIMS score of 5, indicating severe cognitive impairment, and he was wheelchair-bound and dependent on staff for bed mobility, transfers, dressing, and toileting, requiring 1–2 staff assistance and a mechanical lift per his care plan.

On the morning in question, surveyors observed the resident seated in his wheelchair in front of the nurse’s station with a clear cup of white liquid spilled on his dark gray pants at 8:50 a.m. At 9:15 a.m., he remained in the same location with the white liquid still on his pants and a small puddle of the substance under his wheelchair, while multiple staff members walked past him and sat at the nurse’s station. At 9:23 a.m., the resident was still in front of the nurse’s station with the absorbed white substance visible on his pants and under his wheelchair. By 9:51 a.m., the spill on the floor had been cleaned, but the resident’s pants still had a wet area on the left upper thigh.

Later that morning, at 11:45 a.m., a CNA wheeled the resident toward the dining hall, stating his pants were dry but then took him to his room to change his clothing. At 11:55 a.m., the CNA and a COTA used a mechanical lift to transfer the resident, provided incontinent care, and changed his clothes. During this process, surveyors observed a white substance on the wheelchair and noted the lift sling was wet, requiring a clean sling before transferring the resident back. In interviews, the CNA reported she had gotten the resident up, dressed, and fed breakfast earlier, believed he had a health shake, and acknowledged that aides were responsible for ensuring he was clean and dry. Other staff, including a CMA, CNA, LVN, ADON, DON, and the administrator, all stated that residents should be kept clean and dry, that all staff share responsibility for addressing soiled clothing, and that leaving a resident in dirty clothes is a dignity issue. The facility’s Resident Rights policy states that residents have the right to be treated with respect and dignity.