§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 facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to provide appropriate treatment and services to assist a resident in maintaining or improving bowel and bladder continence to the extent possible for one of two sampled residents reviewed for continence care. (Resident R7)
Findings:
Review of the clinical record revealed Resident R7 was admitted to the facility on April 28, 26.
Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated May 4, 2026 included diagnoses of benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate), malignant neoplasm of the prostate (prostate cancer), unspecified dementia, unspecified severity, without behavioral disturbance (memory impairment), low back pain (back pain), and thyrotoxicosis without thyrotoxic crisis or storm (overactive thyroid). The resident's Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive impairment. Section B: Hearing indicated that Resident R7 has moderate difficulty hearing. Under Hearing Aids, it was incorrectly coded that Resident R7 does not use a hearing aid or other hearing appliance to assist with hearing.
Review of the physician orders Resident R7 was prescribed Lasix 20 mg (furosemide) which is a loop diuretic, commonly called a "water pill." It helps the body get rid of excess fluid by increasing urine production.
A review of the comprehensive care plan, most recently reviewed on April 29, 2026, revealed that it did not include goals and/or interventions related to maintaining bowel and bladder continence, including toileting assistance and continence management interventions.
The comprehensive care plan only identified a focus area indicating that Resident R7 required moderate assistance from two staff members for scoot-pivot transfers. The associated goals stated that Resident R7 would perform bed mobility with supervision and transfer with supervision. The care plan did not address the resident's bowel or bladder continence status, toileting needs, scheduled toileting program, continence management, or staff assistance required to maintain continence to the extent possible.
On May 26, 2026, at 9:40 a.m., Resident R7 was observed lying sideways in bed unclothed and without bed linens. Fecal matter was observed on the resident's buttocks and side. During the observation, Certified Nursing Assistant (CNA), Employee E5, entered the room, spoke with Resident R7, and reported that the resident had finished having a bowel movement, wanted to get dressed, and wanted assistance transferring to his chair. Fecal matter was also observed on Resident R7's toilet. At 9:46 a.m., the toilet remained visibly soiled with fecal matter. Licensed Nurse, Employee E3, who was present during the observation, confirmed that the toilet was dirty and stated that she was unsure where the assigned CNA was or why Resident R7 had been left unclothed, without bed linens, and with fecal matter remaining on his buttocks. Employee E3 stated that she would ensure the resident received assistance.
On May 26, 2026, at 10:21 a.m., an interview was conducted with Licensed Practical Nurse (LPN), Employee E3, who identified herself as Resident R7's assigned nurse. Employee E3 reported that Resident R7 speaks limited English and exhibits behaviors that affect his continence care. Employee E3 stated that the resident will at times urinate on himself and in his bed and then use the call bell requesting staff assistance for cleanup. Employee E3 further reported that the resident frequently removes his incontinence briefs, which contributes to challenges in managing his urinary continence and personal hygiene needs.
On May 27, 2026, at 9:28 a.m., an interview was conducted with Physical Therapist, Employee E6, while Resident R7 was participating in a therapy session. Resident R7 was observed to be appropriately dressed and compliant with therapy. Employee E6 reported that Resident R7 was unable to ambulate and was receiving physical therapy to improve lower extremity strength and transfer abilities. When asked whether Resident R7 exhibited noncompliant behaviors or whether Employee E6 had observed the resident intentionally urinating on himself or his surroundings, Employee E6 stated no. Employee E6 further reported that throughout therapy sessions, Resident R7 had been compliant and cooperative with all therapeutic interventions.
On May 27, 2026, at 2:35 p.m., an interview was conducted with Resident R7 and his daughter, who identified herself as the resident's Power of Attorney (POA). Due to the resident's hearing impairment and communication difficulties, the daughter assisted with interpretation. When asked to describe the events of May 26, 2026, Resident R7 reported that after breakfast, at approximately 9:30 a.m. to 10:00 a.m., he activated the call bell approximately five times. Resident R7 was unable to recall how long it took for staff to respond; however, he/she reported that by the time assistance arrived, he/she had already had a bowel movement and required assistance with toileting and hygiene. Resident R7 stated that Certified Nursing Assistant (CNA), Employee E9, informed him/her that he/she needed to use the toilet. According to Resident R7, CNA Employee E9 transferred him/her to the toilet, removed his/her brief, and then left him/her seated on the toilet. Resident R7 reported that CNA Employee E9 provided wet paper towels and instructed him/her to clean himself. Resident R7 stated that he was unable to perform toileting hygiene independently. Resident R7 further reported that CNA Employee E9 left the bathroom area, leaving him/her seated on the toilet for approximately ten minutes.
Resident R7 stated that while waiting for assistance, his/her back began to hurt. Due to the pain and the presence of fecal matter, he/she removed his shirt and used it to cover his wheelchair, which had become soiled with fecal matter. Resident R7 reported that he/she then transferred himself from the toilet to the wheelchair, wheeled himself back to his bed, transferred himself into bed, and remained unclothed until staff returned to provide assistance.
Resident R7 further reported that this was not the first occurrence and stated that a similar incident had occurred again today, during which he/she was left on the toilet and instructed to clean himself/herself using wet paper towels despite being unable to do so independently. Resident R7 also reported that the toilet was unsteady and that the toilet seat moved when in use, causing him to fear falling during transfers and toileting.
Resident R7 reported that staff believed he intentionally urinated or had bowel movements on himself; however, he denied doing so intentionally. Resident R7 stated that due to his/her hearing impairment, his call bell requests were not always answered promptly and that by the time assistance arrived, he/she often no longer needed toileting assistance and instead required incontinence care and changing.
The resident's daughter reported that Resident R7 has a history of enlarged testicles, benign prostatic hyperplasia (enlarged prostate), and prostate cancer, which make urination difficult. She stated that the resident is unable to effectively use a standard urinal and prefers to use a cup for urination. The daughter further reported that the resident is unable to urinate while seated on the toilet due to his enlarged prostate and that when staff place him on the toilet for extended periods, he may urinate on himself because he is unable to void effectively in that position.
On May 28, 2026, at 8:34 a.m., an interview was conducted with the Director of Nursing, who reported that the facility had investigated concerns related to Resident R7's activities of daily living and determined that the resident may be more appropriately accommodated through the use of a female urinal due to his individual needs. The Director of Nursing further confirmed that Resident R7 did not have a care plan addressing his toileting preferences, including his preference for using a cup rather than a standard male urinal, nor did the care plan include interventions related to refusal behaviors, toileting assistance, or individualized continence management strategies.
On May 28, 2026, at 11:15 a.m., Occupational Therapist, Employee E7, reported that Resident R7 required set-up and supervision for upper body self-care and moderate assistance for lower body self-care. Employee E7 stated that the resident required assistance with toileting hygiene, clothing management, and thorough cleansing following bowel movements. Employee E7 further reported that the resident was frequently observed with a wet brief and/or fecal matter during therapy sessions and required staff assistance to wipe himself following toileting. Employee E7 stated that the resident could stand for less than one minute while holding onto grab bars and that family training conducted on May 15, 2026, included instruction regarding the resident's need for assistance with self-care, dressing, and toileting. Employee E7 reported that the resident required assistance with these tasks prior to admission due to a history of falls, chronic pain, back surgery, and limitations related to knee and back pain.
Employee E7 further reported that during family training on May 15, 2026, the resident's daughter stated that the resident preferred using a cup rather than a urinal. Employee E7 indicated that the resident's toileting needs may be better addressed through modification of the urinal or use of a preferred toileting device and stated that additional interventions would be discussed and implemented moving forward.
On May 28, 2026, at 2:45 p.m., an interview was conducted with the Director of Nursing and the Administrator. During the interview, both confirmed that the facility had not implemented individualized interventions to address Resident R7's toileting needs and preferences, including his preferred method of urination, toileting assistance needs, and behaviors impacting continence care. The Director of Nursing and Administrator acknowledged that the facility failed to provide the necessary treatment and services to assist Resident R7 in maintaining bowel and bladder continence to the extent possible.
28 Pa. Code 211.10(a)(d) Resident care policies.
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 06/19/2026
1.Upon identification of the deficient practice, the following were implemented:
- Reviewed with Resident R7 personal toileting preferences
- Education was provided immediately to all direct care staff in the nursing department addressing toileting preferences individualized to your Residents needs and refer to OT for any Resident that may need further assistance with toileting needs
- Resident R7 referred to OT for Eval for appropriate urinal conducive to his condition and preference.
2. All residents have the potential of being affected by this deficient practice.
3. Immediately audit of all residents continence care and toileting preferences was completed.
4. Audits of resident continence care and toileting preferences will be completed to ensure patient and regulatory satisfaction are met, weekly x4, monthly x4, and quarterly x2 and report to QAPI. DON and or designee will be responsible for implementation of the Plan of Correction.
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