The September 16 incident involved a resident who has lived at the facility since 2018 with severe disabilities from stroke, including paralysis on her right side and inability to speak. She requires assistance with all personal care and cannot complete basic mental status interviews.
During the 4:03 PM care session, CNA #1 made multiple procedural errors that inspectors documented in real time. He placed the resident's feeding pump on hold without authorization, then used only six wipes total to clean the woman's genital area.
The assistant wiped front to back on the right side, folded the same wipe, and reused it on the same area. He repeated the process on the left side with three fresh wipes, then used the remaining wipes to clean "down the center of the vagina front to back one time."
Critical steps were skipped entirely. The CNA never separated the labia to clean each side and the center area. He never cleaned the rectal area. He placed a soiled brief directly on the bed before putting on a clean one.
Thirteen minutes later, when confronted by inspectors, the nursing assistant acknowledged his failures. "He confirmed that he did not perform perineal care correctly," the inspection report states. "He stated he was nervous and forgot to follow proper procedure."
The CNA admitted "his actions could cause Resident #4 to develop an infection."
His supervisor, Registered Nurse #2 and Unit Manager for the B Unit, confirmed the substandard care. She also revealed another violation: CNAs are not permitted to operate feeding pumps at all. "Only nurses are authorized to do so," she told inspectors.
The facility's own policy, dated July 12, requires staff to "wash the resident's entire perineal area, and all areas affected by incontinence with a washcloth, soap, warm water, peri-wash or wipes." The policy specifically states to "wash the entire perineal, wash the entire area."
Executive Director's response suggested systemic problems with staff competency. She told inspectors "the State Agency should have picked anyone other than him to do peri care," then added that "all CNAs should be able to perform care correctly."
The Director of Nursing outlined the cascade of errors during her September 17 interview. CNA #1 should have asked a nurse to pause the feeding pump rather than doing it himself, she explained. Feeding pumps "could malfunction and cause harm to the resident if not handled properly."
For the intimate care itself, the nursing assistant should have "performed perineal care correctly, including applying clean gloves before providing care to the buttocks and skin folds." The DON confirmed he failed to follow proper procedures throughout the encounter.
The resident at the center of this violation represents one of nursing homes' most vulnerable populations. Her medical record shows she was admitted in September 2018 with multiple stroke-related conditions: hemiplegia and hemiparesis affecting her right side, dysphasia, aphasia, and gastroesophageal reflux disease.
Her August 2025 assessment revealed a Brief Interview for Mental Status score of zero, indicating she was "unable to complete the interview." This cognitive impairment makes her entirely dependent on staff for proper care and unable to advocate for herself when procedures go wrong.
Improper perineal care poses serious health risks for elderly residents, particularly those with limited mobility and compromised immune systems. Inadequate cleaning can lead to urinary tract infections, skin breakdown, and other complications that can be life-threatening for frail nursing home residents.
The violation occurred during a complaint inspection, suggesting someone reported concerns about care quality at the facility. Federal inspectors classified this as causing "minimal harm or potential for actual harm" affecting "few" residents, though the classification doesn't diminish the significance for the individual woman involved.
The nursing assistant's admission that he was "nervous" during the procedure raises questions about staff training and supervision at Chadwick Community Care Center. His acknowledgment that he "forgot proper procedure" for such basic care suggests gaps in either initial training or ongoing competency verification.
For Resident #4, now in her seventh year at the facility, this incident represents a fundamental breach of dignity and safety during one of the most vulnerable moments of daily care.
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
- View all inspection reports for Chadwick Community Care Center
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