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 severe cognitive impairment, dementia, and Alzheimer’s disease was documented as needing meal setup assistance and was supposed to eat independently after setup. During observation, an NA left the resident sitting on the edge of the bed with the breakfast tray out of reach and the food still covered, and did not return to set up the meal. A housekeeper later moved the tray within reach, uncovered the food, heated the meal, and unrolled the silverware, after which the resident ate independently. The RN and DON stated nursing should have ensured the meal was set up appropriately.
A resident with highly impaired hearing and who spoke Hmong did not have effective communication supports consistently used despite care plan directions to use an interpreter service and communication binder. Staff were unsure of the resident’s language, and during observation the resident was seen wandering, pulling at his pants, urinating in common areas, and squatting behind equipment while staff were not observed using the interpreter line or communication binder to assess his needs.
Failure to Provide Routine Nail Care: A resident with paraplegia and extensive ADL assistance needs was found with fingernails over 1/4 inch past the fingertips and brown substance under the nails. The resident stated no one had offered nail care, and the aide confirmed he had not offered to trim or clean the nails. The RN and DON stated nail care should be checked and provided on bath days and as needed, but the record did not show completed nail care before the survey.
A resident with dementia and severely impaired cognition, whose preferred language was Cantonese, did not have a communication board in the room. RNA confirmed the resident did not speak or understand English and stated that non-English speaking residents should have a communication board with pictures and descriptions in their spoken language to help communicate basic needs. The DON also stated that non-English speaking residents should have a communication board to express needs and help staff address them appropriately.
The facility failed to maintain communication ADLs for two residents with hearing and speech deficits. One resident had cognitive communication deficit and bilateral hearing loss, but no care plan or assistive devices were available during survey interviews. Another resident had bilateral sensorineural hearing loss, unclear speech, and communicated by lip reading and sign language, yet the care plan lacked communication interventions and no communication board or interpreter was present. An LPN stated staff just talked loud and mouthed words, and the NHA confirmed the care plans were not individualized.
A resident with Alzheimer's disease, dementia, and severe protein-calorie malnutrition had a care plan for a restorative nursing program for eating, with staff to cue her to use utensils. During meal observations, she was seen using her fingers to eat instead of utensils, and staff did not redirect or cue her. The DON confirmed staff were to assist the resident with eating.
Failure to Provide Meal Setup Assistance
Penalty
Summary
The facility failed to provide setup meal assistance for a resident with severe cognitive impairment, dementia, and Alzheimer’s disease who was documented on the MDS as requiring setup or clean up assistance with eating and substantial/maximal assistance with mobility. The resident’s care plan stated she was independent with eating after setup, and a family member reported that she needed her silverware placed out or she would eat with her fingers. During observation, a nursing assistant helped the resident sit on the edge of the bed, left to get the breakfast tray, and did not return to set up the meal even though the resident remained in bed with the tray table out of reach and the food covered with silverware still rolled in a napkin. A housekeeper later noticed the tray was not within the resident’s reach, moved the tray table in front of her, uncovered the food and beverage, heated the meal, and unrolled the silverware. After that, the resident drank juice and ate breakfast independently. The nursing assistant stated the resident could eat independently after everything was set up and that if lids were not removed she often would not know what to do and would not eat. The RN stated the meal should have been set up by nursing with the tray within reach, and the DON stated a resident needing meal setup assistance should have the tray set up appropriately and within reach. The facility policy stated assistance with tray setup and uncovering food items would be provided as needed and items would be placed conveniently for the individual.
Failure to Use Communication Supports for a Hearing-Impaired, Non-English-Speaking Resident
Penalty
Summary
The facility failed to implement interventions for a resident who required alternate means of communication due to hearing loss and being non-English speaking. The resident’s MDS indicated highly impaired hearing with no hearing aid or other hearing appliance, and the care plan and banner directed staff to use an interpreting service and a communication binder, but neither identified the resident’s language. The care plan also directed staff to anticipate and meet toileting needs, and the resident had orders for 15-minute safety checks, admission to the locked memory care unit, and close monitoring for safety. During interviews, nursing staff stated they were unsure what language the resident spoke or what the expected process was for communicating with him. The nurse manager stated the resident spoke Hmong and staff were supposed to use the translator during care, but staff were not observed doing so consistently. The nurse manager also stated that if the resident did not understand the interpreter, staff should attempt to use the communication binder to assess his needs. During continuous observation, the resident was seen wandering in the non-locked common area, pulling at his pants, talking to himself in a non-English language, urinating in the common area and later on a wall, and squatting behind equipment where stool was found afterward. Staff were observed at times nearby, but they were not observed using an interpreting service or the communication binder to attempt communication or assess the resident’s needs. The facility’s communication and language access policy indicated the resident’s primary language should be placed prominently in the electronic health record.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to ensure routine and as-needed nail trimming and cleaning were completed for one resident who required staff assistance with ADLs. The resident had intact cognition, was diagnosed with paraplegia and not diabetes, and required setup/clean-up assistance with eating, supervision or touching assistance with oral hygiene and personal hygiene, and was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on and taking off footwear. The care plan called for a weekly body audit, and the Weekly Bath and Skin Sheets on several dates documented the resident's fingernails as short and smooth and not needing trimming, with no further completed sheets found and no documentation showing the resident received nail care before the survey start. During observation and interview, the resident was seen in bed with fingernails over 1/4 inch beyond the fingertips and brown substance underneath the nail tips. The resident stated no one had offered to help cut or clean the fingernails, and the aide assisting the resident stated he had not offered to help with nail care and did not think the resident could cut the nails independently. The RN stated aides should assist with trimming and cleaning nails on shower days and as needed, and the DON stated nursing staff should be checking nail status and trimming and cleaning as needed and on bath days if indicated. The facility policy stated nail care should be completed on bath days and as needed.
Failure to Provide Communication Board in Resident’s Preferred Language
Penalty
Summary
The facility failed to ensure that a non-English speaking resident was provided with a communication board or device in a language the resident understood. Resident 2 was admitted with diagnoses including dementia, anxiety, and a history of falling. The resident’s MDS dated 5/7/2026 identified Cantonese as the preferred language and indicated severely impaired cognition for daily decision making. The MDS also showed the resident required partial/moderate assistance with oral hygiene, upper body dressing, and personal hygiene, and was dependent for toileting, showering, and lower body dressing. During observation and interview, Resident 2 was speaking a language other than English, and RNA 1 stated the resident spoke Cantonese and did not speak or understand English. RNA 1 also stated Resident 2 did not have a communication board in the room, and that residents whose primary language was not English should have a communication board with pictures and descriptions in their spoken language to help communicate basic needs. The DON stated that all non-verbal, alert and oriented residents and non-English speaking residents should have a communication board in the room to express needs and allow staff to address those needs appropriately. The facility policy on Effective Communication stated staff would communicate with residents using techniques identified in the plan of care, including communication boards or writing materials.
Failure to Support Communication Needs
Penalty
Summary
The facility failed to implement care and services to maintain residents’ activities of daily living related to communication for two residents with hearing and speech deficits. One resident had diagnoses including cognitive communication deficit, dysphagia, and depression, and an audiology assessment documented bilateral hearing loss and refusal of an amplifier. The resident was noted in a progress note to be very hard of hearing and difficult to understand, and during survey interviews the resident was non-interviewable because of inability to hear and had no assistive devices available for communication. The clinical record did not include evidence of a care plan for the resident’s hearing and communication deficits. A second resident had a care plan identifying a potential communication problem due to bilateral sensorineural hearing loss and speech/language delay related to hearing loss, but the care plan did not include interventions for how to communicate with the resident. The resident’s MDS indicated highly impaired hearing and unclear speech, and an audiology evaluation stated the resident had hearing loss, did not use amplification, and communicated through lip reading and sign language. During survey interviews, the resident stated he was deaf, and there was no communication board or interpreter present. Staff stated one resident knew sign language and could interpret, and an LPN confirmed both residents had no assistive devices for communication and that she just talked loud and mouthed words. The NHA confirmed the residents’ care plans were not individualized and that the facility failed to implement care and services to maintain communication abilities.
Failure to Cue Resident to Use Utensils During Meals
Penalty
Summary
The facility failed to provide services to maintain or improve activities of daily living for Resident 153, who had diagnoses including Alzheimer's disease, dementia, and unspecified severe protein-calorie malnutrition. The care plan identified a self-care deficit and included a restorative nursing program for eating, with staff to assist by giving cues to encourage the resident to use utensils. During observation on May 18, 2026, Resident 153 was seen in the dining room at lunch using her fingers to scoop ice cream instead of using a spoon, and staff did not redirect or cue her to use utensils. On May 19, 2026, the resident was again observed eating her lunch with her fingers while a nurse aide was seated at the same table, and staff again did not redirect or cue her to use utensils. The Director of Nursing later confirmed that staff were to assist Resident 153 with eating.
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