F0677

D

Failure to Provide Timely Incontinence Care and ADL Assistance

Rockford, Illinois Survey Completed on 12-10-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely ADL care, specifically incontinence care, to a resident who required assistance. The resident was admitted with diagnoses including anorexia, polyarthritis, excoriation disorder, difficulty walking, and paranoid schizophrenia, and had a care plan effective September 20, 2025, indicating she was at risk for skin breakdown related to bowel and bladder incontinence and directing staff to ensure she was kept clean and dry and changed as needed. On December 8, 2025, at 11:20 AM, a CNA (V9) used a mechanical stand lift to transfer the resident, revealing a large wet circle on the back of the resident’s pants and a strong urine odor. When the CNA placed the resident on the toilet and removed her incontinence brief, the resident was found to be wearing both a thick disposable incontinence pad and an incontinence brief, both saturated with urine; the CNA stated the resident had been up in her wheelchair since about 8:00 AM and that the extra pad and brief were used because the resident was a heavy wetter. Another CNA (V12) later stated that incontinence care should be provided at least every two hours and as needed, that residents should only wear one incontinence brief at a time, and that heavy wetters should be checked and changed more frequently. The facility’s ADL policy states that residents unable to carry out ADLs will receive necessary services to maintain good grooming and personal hygiene, but the observed condition of the resident’s saturated incontinence products and clothing demonstrated that timely incontinence care was not provided in accordance with the care plan and policy.