The violation occurred on September 16 during perineal care for Resident #4, a person who has lived at Chadwick Community Care Center since 2018 with multiple conditions stemming from stroke, including right-side paralysis, difficulty swallowing, and speech problems. The resident scored zero on a mental status exam, indicating an inability to complete basic interview questions.
CNA #1 performed the intimate care alone at 4:03 PM, despite the resident's comprehensive care plan explicitly stating "2-person assistance for total dependence" during incontinence checks and care every two hours.
When confronted 13 minutes later, the nursing assistant admitted the violation. "He confirmed that he did not follow the care plan by using 2 persons for assistance with perineal care," inspectors documented.
The care plan had been in effect since October 2024, nearly a year before the violation occurred. It identified the resident as "incontinent of bladder and bowel" and required the two-person protocol specifically because of total dependence.
Executive Director's response revealed systemic expectations weren't being met. "All CNAs should be able to provide care correctly," she told inspectors the evening of the violation.
The Director of Nursing confirmed the failure the next morning. "CNA#1 did not follow the care plan," she stated, adding that her expectation "is for CNA's is to give good quality care and follow proper procedure for giving care."
But the facility's own MDS nurse, Registered Nurse #2, deflected responsibility when questioned about the incident. "She could not comment on what CNA #1 did or did not do, she was not there when he provided the care," according to the inspection report.
The nurse then explained the obvious. "She stated I can only say what the care plan says. The care plan states (2) people assistance with peri care."
She added that care plans exist "to inform the CNAs of the care that is to be provided" and that "the interventions indicate what the facility is doing for the residents."
Resident #4's medical complexity makes the two-person requirement particularly critical. Admitted in September 2018 with hemiplegia and hemiparesis affecting the right side following stroke, the resident also lives with dysphasia, aphasia, and gastroesophageal reflux disease.
The zero score on the Brief Interview for Mental Status indicates complete cognitive impairment, meaning the resident cannot communicate needs, discomfort, or concerns during personal care.
Federal inspectors observed the violation during a complaint investigation at the 1900 Chadwick Drive facility. The comprehensive care plan, reviewed during the inspection, dated back to January 25 and stated that "each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences and goals that will identify how the interdisciplinary team will provide care."
The violation represents a breakdown in the most basic nursing home function: following individualized care plans designed to protect vulnerable residents during intimate personal care.
For Resident #4, who has spent more than six years at Chadwick Community Care Center managing the aftermath of stroke, the failure meant receiving personal care without the safety protocols specifically established for their protection.
The facility's leadership acknowledged the violation occurred but provided no explanation for why established protocols weren't followed, leaving questions about supervision and training that allowed a nursing assistant to ignore explicit care plan requirements for a completely dependent resident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chadwick Community Care Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
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