Accel at Willow Bend: Improper Incontinence Care - TX
The incident occurred on August 19 at Accel at Willow Bend when CNA P was observed providing care to Resident 41, an elderly woman with severe cognitive impairment who was frequently incontinent of bowel and bladder.
Federal inspectors watched as the nursing assistant entered the resident's room at 2:56 PM, washed her hands, put on gloves and unfastened the resident's soiled brief. The resident had been incontinent of urine.
CNA P pushed the soiled brief down between the resident's legs and cleaned her perineal area from front to back. But she failed to separate the resident's labia and clean down the middle, missing a critical step in proper female incontinence care.
The assistant then rolled the resident onto her side, revealing she had soaked through her brief. CNA P continued wiping the resident's buttocks from back to front before applying a clean brief, removing her gloves and washing her hands.
Six minutes later, inspectors interviewed the nursing assistant about what they had witnessed.
CNA P acknowledged she had failed to separate the resident's labia during cleaning. She also admitted to wiping the resident's buttocks from back to front, confirming she had provided inappropriate incontinence care that could lead to infection.
"She stated she had been in training and knew the importance of properly cleaning a resident," inspectors wrote.
The resident at the center of the violation was particularly vulnerable. Her quarterly assessment showed she had dementia and elevated blood pressure. Her cognitive abilities were severely impaired, with a score indicating she could not make decisions about her own care.
She was frequently incontinent of both bowel and bladder, making proper cleaning protocols essential to her health and dignity.
The facility's own care plan for the resident specifically called for providing "incontinent care after each incontinent episode" with the goal of maintaining or improving her elimination status over 90 days.
The next day, the Director of Nursing explained to inspectors what should have happened during the resident's care.
"When providing incontinent care, staff were to clean the peri area including the labia for female residents, then moving toward the buttocks and always clean from the front to back," the DON told inspectors.
He acknowledged the serious consequences of improper technique: "By not providing accurate incontinent care it placed residents at risk for urinary tract infections, skin breakdown and overall poor hygiene."
The facility's own policy, dating to April 2012, spelled out the correct procedure in detail. For female patients, staff must "separate the labia and wash downward (down the center of labia), then downward on each side of the labia using a different per wipe with each stroke."
The policy also required cleaning "outer hip of buttocks going upwards towards back" — the opposite direction from what CNA P had done.
The DON promised to monitor compliance "by doing skills check on all CNAs periodically."
But for Resident 41, the damage was already done. The woman with severe dementia, who depended entirely on staff for her most basic care, had been left vulnerable to the very infections the protocols were designed to prevent.
Federal inspectors found the facility failed to ensure appropriate treatment and services to prevent urinary tract infections, citing minimal harm with potential for actual harm to few residents.
The violation occurred despite clear policies and training requirements that the nursing assistant herself acknowledged knowing. CNA P told inspectors she understood "the importance of properly cleaning a resident" even as she admitted to cutting corners during the most intimate aspects of patient care.
For families placing loved ones with dementia in nursing homes, the incident highlights how fundamental care can break down at the most vulnerable moments — when residents cannot advocate for themselves and depend entirely on staff to follow basic hygiene protocols that protect their health and dignity.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accel At Willow Bend from 2025-08-21 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 20, 2026 · Our methodology
ACCEL AT WILLOW BEND in PLANO, TX was cited for violations during a health inspection on August 21, 2025.
The resident had been incontinent of urine.
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.