The nursing assistant responsible for Resident #162's care had provided incontinence care once that morning at 9:45 AM, then never returned. She couldn't get help for the two-person transfer required to safely change the resident.
"There were no staff members seen in the hall to assist her," the nursing assistant told inspectors during a September phone interview. She explained that Resident #162 required two people for bed mobility, but with 20 to 30 residents assigned to her alone, getting assistance was impossible.
The facility has been chronically short-staffed since April 2025, according to inspection records. Nursing Assistant #10 typically handled 26 residents during her 12-hour shift from 7 AM to 7 PM. When assigned to the 700 hall, that number jumped to 40 residents.
"When she had that many residents assigned to her, she couldn't get baths or showers done," inspectors documented. Weekend showers frequently went undone because of inadequate staffing levels.
The wound nurse who discovered Resident #162 in the soaked conditions immediately reported the situation to the Director of Nursing at 5:25 PM on August 20, 2025. He instructed her to complete a grievance form, which she did. She also reported the incident to Unit Manager #1.
But the nursing assistant assigned to Resident #162 told investigators the facility's staffing crisis made proper care nearly impossible. She had worked daily for three months and described constant understaffing that left nursing assistants responsible for up to 30 residents during 12-hour shifts.
"It was impossible to complete her tasks when she had 20 to 30 residents," she explained to inspectors. Incontinence care was provided, she said, but "there was normally a delay with completing it."
The nursing assistant confirmed she had done one round on Resident #162 after breakfast, providing incontinence care at approximately 9:45 AM. She never returned because she couldn't safely provide care without help that wasn't available.
"The facility was not equipped to provide safe and adequate care to residents due to being short staffed all the time," she told inspectors.
Unit Manager #1 confirmed the incident when interviewed on September 11. She recalled the wound nurse notifying her that Resident #162's brief and sheets were soaked with urine. When she spoke to the nursing assistant, "she told her she had not provided incontinent care to Resident #162 yet because she was behind with her tasks."
The unit manager acknowledged the facility had several call-outs on August 20, making it difficult for nursing assistants to complete their responsibilities. She had personally witnessed nursing assistants handling up to 20 residents each during first shift.
"The facility did have several call outs on 08/20/25 and it was hard for the NAs to complete their tasks when they had call outs and were short staffed," she explained. Care was provided, she said, but it was delayed.
The shower schedule reflected the broader staffing problems. Nursing Assistant #10 noted that the shower sheet posted at the nurse's station didn't match what appeared in the computer system. Weekend showers were frequently skipped entirely due to insufficient staff coverage.
The most recent time she recalled having 40 residents assigned to her was in August, though she couldn't remember the exact date or shift.
Director of Nursing recalled the wound nurse's report about Resident #162's brief, sheets, and blankets being saturated with urine. After instructing the nurse to complete a grievance form, he conducted an educational in-service for nursing assistants and took disciplinary action against the direct care nursing assistant.
However, the inspection report provides no indication that anyone investigated the underlying grievance the wound nurse filed, or whether the facility addressed the systemic staffing shortages that led to the incident.
The nursing assistant who cared for Resident #162 remained blunt about the facility's capacity to provide adequate care. With chronic understaffing leaving individual workers responsible for up to 30 residents during 12-hour shifts, she said delays in basic care like incontinence management had become routine.
Resident #162 spent at least seven and a half hours lying in urine-soaked bedding and clothing before the wound nurse's 5:25 PM discovery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Blumenthal Health and Rehabilitation Center from 2025-09-13 including all violations, facility responses, and corrective action plans.
Additional Resources
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