F0677

D

Failure to Provide Timely Incontinence Care and Clothing Changes for Dependent Residents

Kannapolis, North Carolina Survey Completed on 03-18-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to provide timely incontinence care and assistance with changing soiled clothing for two dependent residents. Resident #18, admitted with dementia and care planned for bowel and bladder incontinence, was documented as severely cognitively impaired, always incontinent, and dependent on staff for toileting hygiene. During a continuous observation from 1:03 PM to 1:25 PM, he was seen lying in bed with his brief exposed and the bed sheet beneath him visibly wet with a straw-colored area approximately 10 inches around his lower body, surrounded by a yellowish-brown dried border about 3 inches wide. No nursing assistants were present on the hall during this observation. The DON later confirmed that the resident’s clothing, brief, and linens were wet and required changing, and another NA verified that his clothing, brief, and linens were wet with urine.

Nursing Assistant #6, identified as the direct care NA for Resident #18, stated she had provided incontinence care between 8:15 AM and 8:30 AM and that at 11:30 AM she found his brief wet and in need of changing, but reported the resident refused care. She stated she notified Nurse #2 of this refusal, did not return to the resident’s room after 11:30 AM, and went to lunch at 1:30 PM without changing him, explaining that she needed to get food. NA #7, who was orienting with NA #6, confirmed they had provided incontinence care around 8:30 AM and that on a later visit before lunch the resident said he was tired and asked them to return later; he stated that neither he nor NA #6 returned before lunch and that he was not aware of any notification to Nurse #2 about a refusal. Nurse #2 later reported that NA #6 had not notified her at any time that the resident had refused incontinence care.

The deficiency also includes failure to ensure a resident’s clothing was changed when soiled. Resident #87, admitted with intermittent explosive disorder and vascular dementia, was severely cognitively impaired and required substantial assistance with dressing. Observations on one day at 11:43 AM and 2:52 PM showed him in bed wearing a long-sleeved shirt with dried food particles and dried white and tan spill marks while he was eating lunch and later resting. The following morning at 10:00 AM, he was again observed wearing the same soiled shirt, still with dried food and spill marks; he stated he had been wearing it for three days and that it needed to be changed, though he was unsure if he had asked anyone to change it. A medication aide confirmed the shirt was soiled and the same one from the previous day and stated she assumed the assigned NA would have changed it during morning care or after lunch the prior day. The NA assigned to him on the second day acknowledged she had not yet provided morning care when notified around 10:30 AM that his shirt was soiled and had been worn since the previous day, and then went to provide care. The DON stated residents were expected to remain neat, clean, and dressed in clean garments, and that staff were expected to change clothing after meals if soiling occurred, and reported she was not aware that this resident’s ADL needs had not been met.