F0677

D

Failure to Provide Timely Incontinence Care to Dependent Resident

North Aurora, Illinois Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely incontinence care and assistance with activities of daily living to a dependent resident with severe dementia. On 1/13/2026 at 10:10 AM, the resident was observed in bed wearing a gown, severely confused and fidgeting, with a strong foul urine odor in the room and incontinence products on the bedside table. At 11:00 AM, the resident remained in bed with the same strong foul urine smell. The RN (V14) stated that providing incontinence care was difficult because the resident tended to resist due to severe dementia. Upon assessing the resident’s incontinence brief, V14 found it soiled with urine and emitting a strong foul odor. The resident had two cloth pads underneath her, with the top pad soiled by a dark yellow stain that V14 said was dry, and V14 was unsure when the resident last received incontinence care.

At 11:20 AM, two CNAs (V12 and V13) stated they were going to provide incontinence care to the resident. V12 reported that she had last provided incontinence care around 8:00 AM and, upon assessing the soiled cloth pad, believed it had not been present previously and was now dry. The resident’s care plan documented cognitive impairment and a need for assistance with ADLs, including toileting, with interventions directing staff to provide total incontinence and hygiene care. The DON (V2) stated that nursing staff were expected to check residents for incontinence at least every two hours and as needed, and that this resident should have received timely incontinence care, including premedication with PRN antianxiety medication if necessary to allow staff to meet basic toileting needs. The facility’s incontinence care policy dated 05/2025 stated that all incontinent residents would receive appropriate treatment and services based on their comprehensive assessment.