The September 11 discovery occurred at 10:01 a.m. during a wound care observation. Inspectors noted the resident had "a foul odor of urine" and their brief was "soaked with urine."
Resident #100 told inspectors they had not received a brief change or a bath.
Five minutes later, the certified nursing assistant assigned to the resident confirmed they "had not been able to perform incontinent care for Resident #100 during this shift."
The resident's care plan, dated August 5, specifically required staff to "check and change the resident and keep them clean and dry." An assessment from August 9 showed the resident was frequently incontinent of urine and required partial to moderate assistance with daily activities.
The resident's cognitive abilities were severely compromised, with a score of 7 on a standardized mental assessment where higher scores indicate better function. Medical diagnoses included chronic obstructive pulmonary disease, diabetes, and dementia.
A regional nurse consultant told inspectors on September 17 that incontinent care should be offered to residents like this "frequently, at least every two hours."
The facility also failed to provide regular showers to another resident during their stay earlier this year.
Resident #127 was admitted in early April and discharged on April 24. Bath records showed the resident received showers on April 16, 20, and 23. But there was no documentation showing any showers between April 3 and April 16 — a gap of nearly two weeks.
An unidentified charge nurse explained the shower system to inspectors on September 10. A list posted at the nurse's station showed room numbers and scheduled shower days. Once completed, the charge nurse signed off on the sheet.
The charge nurse acknowledged "sometimes showers were missed if staff did not show up to work."
A certified nursing assistant told inspectors that residents sometimes refused showers. In those cases, staff were supposed to discuss "the importance of hygiene" and report continued refusals to the charge nurse. The assistant said there was enough staff to provide showers.
The inspection was conducted in response to a complaint. Ranchwood Nursing Center houses 109 residents according to the director of nursing.
The violations represent failures in basic hygiene care that federal regulations require nursing homes to provide. Residents who cannot perform activities of daily living independently must receive assistance from staff.
For Resident #100, the failure meant sitting in waste while dealing with multiple serious medical conditions. The resident's severe cognitive impairment would have made it difficult to advocate for proper care or understand why help wasn't coming.
The shower documentation gap for Resident #127 occurred during what appeared to be a short-term rehabilitation stay, when consistent hygiene care is essential for recovery and preventing infections.
Both violations were classified as causing "minimal harm or potential for actual harm" to residents. The inspection occurred on September 17, nearly five months after Resident #127's discharge and six days after inspectors observed Resident #100's condition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ranchwood Nursing Center from 2025-09-17 including all violations, facility responses, and corrective action plans.