§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.
§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.
§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
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Observations:
Based on review of facility's policy, observation, clinical records review and staff interviews, it was determined that the facility failed to ensure incontinent care was provided for one of two residents reviewed (Resident 1).
Findings include:
A review of the facility's policy titled "Urinary Continence and Incontinence - Assessment and Management" , dated 2001, revealed that the staff and management will appropriately screen for, and manage, individuals with urinary incontinence. The staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.
A review of Resident 1's Quarterly MDS Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated August 12, 2025, revealed resident was frequently incontinent of bladder and was dependent with toileting.
An observation conducted on October 30, 2025, at 11:00 a.m., in the presence of unlicensed Employee E3 revealed resident laying in bed wearing a blue gown, with disheveled hair. Additional observations revealed resident's incontinence breif was soaked with dark yellow/light brown urine.
An interview conducted with Nursing Employee E3 on October 30, 2025, at 11:05 a.m. revealed that she/he was the resident's morning aide. Nursing Employee E3 reported that she got in today at 7:00 a.m. but had to pass breakfast tray then prepare residents scheduled for hair salon in the morning. Employee E3 confirmed that she/he has not provided incontinent care to Resident 1 since 7:00 a.m. Employee E3 reported that the night shift must have provided incontinent care but not sure when.
A review of the Resident 1's "task" revealed that Resident 1 was last observed incontinent on October 30, 2025, at 1:08 a.m. The same documentation revealed that at 1:08 a.m., toileting hygiene was marked as "not applicable" .
An interview with the Director of Nursing on October 30, 2025, at 2:00 p.m., confirmed that Resident 1 was not provided with incontinent care timely.
The facility failed to ensure Resident 1 was provided with incontinent care as needed.
28 Pa. Code 211.10(c) Resident Care Policies
28 Pa. Code 211.12(c)(d)(3) Nursing Services
| | Plan of Correction - To be completed: 11/27/2025
R1 had incontinent care provided.
To identify potential affected residents' DON/designee will complete a review of current incontinent residents to ensure appropriate incontinent care schedule is in place.
To prevent this from happening again DON/designee will re-educate nursing staff on incontinent care policy and procedure and to complete incontinence care per task/Kardex.
To monitor and maintain compliance DON/designee will randomly audit incontinent residents to ensure incontinence care completed timely weekly x 4 weeks. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations.
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