Failure to Provide Timely Incontinent Care Resulting in Saturated Bed Linens
Summary
Surveyors identified a deficiency in the facility’s provision of activities of daily living related to hygiene, grooming, and incontinent care for one cognitively intact resident. The resident, an older female with multiple medical diagnoses including cerebral infarction, COPD, dysphagia, DM2, bipolar disorder, heart failure, hyperlipidemia, CKD stage 3, and seizures, was dependent for peri-care/toilet hygiene, bed mobility, transfers, and lower body dressing, and was incontinent of bowel and bladder. Her care plan and physician orders reflected incontinence, diuretic use, and risk for skin breakdown, with topical Nystatin ordered for yeast infection in the groin and abdominal folds. The DON stated an expectation that nursing staff round at least every two hours to ensure incontinent care needs are met. On one date, the resident reported she had been left in a soiled brief for over five hours, resulting in bed linens saturated with urine. The Ombudsman corroborated that on that date, at approximately late morning, she found the resident crying and “soaking wet,” and allowed the resident to call the state hotline. The Ombudsman reported notifying the ADON and observing aides enter the room to provide peri-care while she spoke with the ADON. On a later observation date, the resident told the surveyor she was soiled with urine and waiting to be changed; the surveyor noted a slight urine odor and a brief that was not saturated and appropriately sized, and also noted the resident’s call light was not on during that interview. Staff interviews showed that CNAs, hospitality aides, an LVN, the ADON, and the DON all acknowledged the resident used XXL briefs kept in her room and typically used the call light when she needed to be changed. Multiple staff members, including CNAs and hospitality aides, stated they did not recall the resident being found soaked or excessively wet, and one CNA working the relevant hall on the date in question stated she was rushed but felt she completed her tasks, though she could not recall how often she checked on the resident. The DON and Administrator both stated expectations that incontinent care be provided as needed and that staff round at least every two hours, but the nurse aide task documentation for the date in question only showed incontinent care checked off by shift without indicating the number of times peri-care was provided. No facility incontinent care or ADL policy was reviewed prior to survey exit. The facility failed to ensure incontinent care was provided every two hours as recommended, resulting in the resident’s bed linens being saturated with urine.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with moderately impaired cognition, occasional bladder incontinence, and a care plan for scheduled toileting was observed in the dining room with an uncovered urinal hanging from his wheelchair armrest and partially filled with urine. Staff noticed the urinal but did not remove it right away, and the resident became angry when an LPN later took it away. The DON stated the urinal should not have been in the common area and that staff should have assisted the resident to the bathroom before he went to the dining area.
Failure to provide ADL assistance and nail care: A resident with dementia and COPD was observed eating lunch in bed without staff assistance and without proper HOB elevation, despite needing partial assistance with meals. Two other residents were observed with long, untrimmed fingernails; one had long nails on both hands, and another had long, jagged, dirty nails with debris under them. Staff and the DON acknowledged the grooming and personal hygiene needs, and the care plans were incomplete for these ADL needs.
Failure to Provide Ordered Restorative Nursing Services: A resident’s care plan called for restorative nursing with cues for ROM of all major joints and Sci-fit exercise 6 to 7 days per week, but the record showed restorative services were only provided on a few days and there was no documentation of refusals on the missed days. The DON confirmed the services should have been provided at least 6 times each week but were not.
Failure to Provide Restorative Services: The facility did not provide restorative nursing services for multiple residents with documented functional dependence and cognitive or physical impairments. Residents stated they wanted therapy or restorative programming to improve mobility, strength, or maintain function, but staff reported the facility had no active restorative program, no current documentation process, and some residents had been discharged from PT without restorative services initiated. The restorative binder listed several residents, but staff said restorative had not been done for months and the program had fallen off.
Failure to provide effective communication for two residents with Russian as their primary language. One resident with dementia and other chronic conditions was sometimes understood, could not communicate with the surveyor, and had no communication aids observed despite a care plan noting a language barrier. Another resident with severe cognitive impairment and a documented Russian language preference was communicated with mainly through gestures and hand motions, while staff reported they had not seen the communication board listed in the care plan.
Failure to supervise a resident on the toilet. A resident with impaired cognition, extensive ADL needs, maximal mobility assistance, and a history of falls related to impulsiveness was left unattended on the toilet for more than 1 hour. The resident was observed sleeping and snoring on the toilet, and staff later assisted the resident off the toilet and to bed. The NA stated the resident liked to sleep on the toilet and that the unit was busy, while the ADON stated residents left unattended on the toilet were expected to be checked at least every 15 minutes.
Urinal Left Hanging on Wheelchair in Dining Room
Penalty
Summary
The facility failed to provide assistance with toileting and elimination by allowing a resident’s urinal to remain hanging on the wheelchair armrest and to be brought into common areas. R33 had moderately impaired cognition, was independent with toilet transfers, required supervision with toilet hygiene and maximum assistance with grooming, and was occasionally incontinent of bladder. His care plan directed staff to assist him with toileting every two to three hours and as needed, keep the urinal within reach of the bed, and offer to bring him to the bathroom after meals to prevent voiding on himself. On 7/14/26, R33 was observed seated in his wheelchair in the dining room playing bingo with an uncovered urinal hanging off the left side of the wheelchair armrest, about a quarter full of yellow liquid. RN-A stated she had not noticed the urinal and said it should not be hanging there and should remain in R33’s room. On 7/15/26, R33 was again observed in the dining room eating supper with an open urinal hanging off the left side of his wheelchair armrest, about half full of yellow liquid. NA-J removed his supper tray but did not acknowledge the urinal. RN-A later stated R33 should not have an open urinal with urine in it in the dining room, but made no attempt to remove it or the resident. LPN-E later removed the urinal from the dining room, and R33 became very angry and attempted to grab it back. The DON stated R33 should not have a urinal in a common area and staff should have assisted him to the bathroom and removed the urinal before he left his room for the dining area.
Failure to provide ADL assistance and nail care
Penalty
Summary
The facility failed to ensure residents maintained independence, functional status, grooming, and personal hygiene for three sampled residents. One resident with dementia, schizoaffective disorder, anxiety disorder, and severely impaired cognitive skills required partial/moderate assistance with eating and oral hygiene and substantial/maximal assistance with upper body dressing. The care plan directed staff to encourage participation in ADLs within the resident’s capability and to keep the head of bed elevated to 90 degrees for meals because of COPD-related airway clearance needs. During observation, the resident was seen eating lunch in bed without staff assistance, with the lunch tray placed across the bed on a bedside table and the head of bed positioned too low. The resident had difficulty reaching the meal. A PTA stated the head of bed was not raised to 90 degrees, and a CNA stated the resident could be left alone because the resident could eat by herself. The MDS nurse later stated the resident required partial assistance during meals and was not positioned correctly, and the PT stated proper positioning during meals was part of the care needed and helped promote easier swallowing and prevent aspiration. The facility policy for in-room meals stated the resident should be positioned as upright as possible. Two other residents were observed with fingernails that were too long and not maintained as part of grooming and personal hygiene. One resident with a history of cerebral infarction affecting the left non-dominant side, major depressive disorder, and hypertension had long fingernails on both hands during observation, and the resident stated the nails needed to be cut. A CNA and the DSD both acknowledged the nails were long and that staff needed to trim them to prevent scratching, skin breakdown, and infection. The DON stated the resident’s ADL care plan was incomplete because it did not include grooming and personal hygiene, and that fingernails should be trimmed at least twice per week. Another resident with lymphedema, bilateral lower-extremity cellulitis, gastroenteritis, and generalized muscle weakness was observed with long, jagged fingernails that were yellowish, dirty, and had blackish-brown debris under them. The resident stated the nails were long and dirty and said staff had been told previously, but the fingernail cart was not available on the weekend. On later observation, the nails remained long and dirty. A CNA and the DSD confirmed the nails were dirty, jagged, and discolored, and the DON stated the ADL care plan was incomplete because it did not include grooming or offering to cut the resident’s long fingernails. The facility’s Nail Care policy stated nail care was to promote cleanliness, safety, and a neat appearance, and the ADL policy stated residents should receive appropriate support and assistance with hygiene, mobility, and dining.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to ensure Resident #12 received treatment and services to maintain or improve the ability to carry out ADLs. The resident’s care plan documented a Restorative Nursing Program to provide cues for movement through tolerated ROM of all major joints and Sci-fit exercise for 15 minutes at level 1-2 resistance, 6 to 7 days per week. However, the medical record showed restorative services were only provided on 6/15/26, 6/20/26, and 6/21/26, with no documentation of resident refusals on 6/16/26, 6/17/26, 6/18/26, 6/19/26, or 6/22/26. The DON stated restorative services for Resident #12 were only provided on 6/15/26, 6/20/26, and 6/21/26 and should have been done at least 6 times each week but were not.
Failure to Provide Restorative Services
Penalty
Summary
The facility failed to provide restorative services to maintain or improve residents’ abilities for 6 of 19 residents reviewed. The deficiency was identified through EHR review, resident interviews, staff interviews, and policy review. The facility’s census was 19, and the report documented that restorative documentation was absent or restorative programs were not active for the affected residents. Resident #12 had an MDS documenting a BIMS of 11, age-related physical debility, generalized muscle weakness, abnormalities of gait and mobility, and a need for assistance with personal care. The EHR contained no restorative documentation. The resident stated he wanted therapy, especially related to falls, and said he did not receive restorative therapy, PT, or OT. A PTA stated the resident was not on her case load and she did not know whether he had a restorative program, while also stating that some residents at the facility would benefit from restorative programming. Resident #18’s MDS documented a BIMS of 14 and dependence for lower body dressing and personal hygiene, with substantial to maximal assistance needed for upper body dressing and bathing. The resident stated she had requested restorative programming and had not received an answer about when she could start, and said she wanted therapy to move better. Resident #19’s MDS documented a BIMS of 15 and dependence with toileting hygiene, with partial to moderate assistance for upper body dressing, lower body dressing, and personal hygiene. He stated he wanted restorative programming to continue gaining strength and return home, and said he had previously received PT but did not know why it stopped. A PTA stated he had been discharged from PT in November 2025 without a restorative program initiated and that he would benefit from restorative services. Staff also stated the facility did not currently have a restorative program because it needed to hire for the position, and the Administrator acknowledged there was no active restorative program. The restorative binder listed Residents #3, #4, and #23, but staff stated restorative had not been done for several months, there was no place to document it, and the restorative had fallen off. The facility policy required assessment, individualized restorative programming, staff education, monitoring, documentation, monthly summaries, therapy referrals as needed, and discharge planning when no longer needed.
Failure to Provide Effective Communication for Non-English Speaking Residents
Penalty
Summary
The facility failed to implement adequate communication for two residents who did not speak English. Resident #50 had diagnoses including dementia, asthma, type 2 diabetes, and hemiplegia/hemiparesis following cerebral infarction affecting the right dominant side. Her MDS showed she was sometimes understood and had a BIMS score of 0, and her care plan identified a communication problem related to speaking Russian. Her activity assessment stated she was born in Russia and spoke Russian as her primary language. A progress note also stated she was difficult to understand due to language barriers and that she watched and listened to Russian television and music stations. During observation, Resident #50 was sitting in her room and was unable to communicate with the surveyor, with no communication devices, boards, or alternative options observed. A CNA stated staff did not know if she used a hearing device, staff could not understand her, she could not understand staff, and they were "just guess[ing]." The resident’s POA stated she was unable to participate in a lot of things due to the language barrier and often sat in her room watching a Russian television channel. The facility’s Non-Discrimination and Accessibility Notice stated it provided aids and services to communicate effectively, including language services, but the report states the facility did not implement the policy. Resident #65 had diagnoses including Alzheimer’s dementia, repeated falls, COPD, and hypertensive heart disease. Her quarterly MDS showed severe cognitive impairment and that she was not usually understood. Admission and re-admission assessments identified Russian as her language, and her care plan documented a communication deficit related to hard of hearing, dementia, and a language barrier, with interventions including use of a vision board. However, staff interviews showed communication was mainly done with hand motions, gestures, facial expressions, and yes/no responses in Russian, and multiple staff members stated they had not seen a communication board in the room or were not aware of one. During observation, she did not speak English and communication could not be completed due to the language barrier. One LPN stated the resident had a fall and, because of the language barrier, was unable to tell what had happened.
Failure to Supervise Resident on Toilet
Penalty
Summary
The facility failed to provide supervision to one resident who was reviewed for activities of daily living and was left unattended on the toilet for more than 1 hour. The resident’s comprehensive MDS assessment identified impaired cognition, extensive assistance needed with ADLs, and maximal assistance with mobility. The care plan noted a history of falls related to impulsiveness and perceived abilities, and included a motion sensor alarm to monitor movements due to unattended or unassisted transfers resulting in falls, along with reminders to use the call light for all transfers. Record review showed the resident had an unwitnessed fall in the bathroom beside the toilet and wheelchair, with the resident’s head leaning against the corner of the doorway. During observation, the resident was assisted onto the toilet by an NA and was later seen sitting on the toilet, chin to chest, sleeping and snoring lightly. Staff returned more than 1 hour later and assisted the resident off the toilet and to bed. During interview, the NA stated the resident could use the call light when ready and had requested more time on the toilet in the past, explaining that 10 to 15 minutes was considered too early. The NA also stated the resident liked to sleep on the toilet and said the unit was busy. The ADON stated the expectation was for staff to check on residents at least every 15 minutes when left unattended on the toilet. Facility policy titled Activity of Daily Living (ADL) Assistance and Functional Maintenance stated to provide supervision and support to residents with balance deficit or fall risks.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.