Touchpoints at Chestnut: Incontinence Care Failures - CT
The incident at Touchpoints at Chestnut violated the facility's own care plan requiring incontinence checks every two hours for the resident, who had no speech and required total assistance from two staff members for all daily activities.
Resident #1 suffered from stroke, left-side weakness, swallowing difficulties and epilepsy. Assessment scores showed severely impaired cognition with a mental status rating of zero. The resident was always incontinent of bowel and bladder.
The care plan dated May 23, 2025 specifically required staff to keep the resident's skin clean and dry, provide incontinence care every two hours and as needed, and turn and reposition the resident every two hours. A physician's order from July 30 reinforced the two-hour turning requirement to help heal a back wound from a medical device.
The Braden scale assessment identified the resident at very high risk for pressure sores.
On July 23, 2025, nursing assistant NA #1 started her shift at 3:30 PM. She checked the resident at 4 PM and found him dry. Then she left to distribute dinner trays between 4:45 and 5 PM.
NA #1 never returned to the room.
At 7 PM, the resident's family member arrived and discovered the patient saturated with urine. The family member also found the resident's feeding tube disconnected, though it was ordered to run starting at 4 PM.
NA #1 heard the family member yelling from the room about the resident being incontinent. In her incident statement, the nursing assistant acknowledged the family member was upset she hadn't checked the resident again at 6 PM as required.
The facility's bladder flowsheet for July 23 showed the resident was incontinent at 12:21 PM and again at 10:19 PM. No documentation existed for any incontinence care between those times, despite the three-hour gap when family found the resident soaked.
RN #1 responded to the family's concerns at 7 PM. She found the resident wet and assessed the genital area for injuries, finding none. The nursing assistant had begun cleaning the resident by the time the RN arrived, preventing her from determining how saturated the patient actually was.
The RN confirmed that incontinent residents should be checked and changed every two hours.
The facility's Director of Nursing Services stated the standard for incontinent residents without capacity to call for help is incontinence checks and care every two hours.
Multiple attempts to interview NA #1 were unsuccessful.
The facility filed a grievance report documenting the family's complaint. An accident and incident form confirmed the resident was found saturated with urine at 7 PM on July 23, with the feeding device disconnected. A skin check revealed no new injuries.
This resident required extensive care due to multiple medical conditions. The skin observation tool from July 22 showed the resident's skin was already compromised due to surgical stitches from a baclofen pump implanted at the base of the spine.
The facility's own continence management policy requires urinary evaluation for residents who are incontinent upon admission or when urinary status changes, with care plans developed based on those evaluations.
Federal inspectors found the facility failed to follow its own care plan requirements for this vulnerable resident. The three-hour gap in required care left a severely impaired stroke patient lying in urine, unable to call for help or reposition himself.
The facility is disputing the citation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Touchpoints At Chestnut from 2025-08-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
TOUCHPOINTS AT CHESTNUT in EAST WINDSOR, CT was cited for violations during a health inspection on August 18, 2025.
Resident #1 suffered from stroke, left-side weakness, swallowing difficulties and epilepsy.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.