Federal inspectors observed the incomplete care during a September complaint investigation at Gillespie Health & Rehab Center. In three separate incidents on September 17, certified nursing assistants failed to properly separate residents' labia during intimate cleaning, violating the facility's own infection prevention protocols.
The most concerning case involved a resident with chronic kidney disease, stage 4, who had tested positive for E. coli just two days earlier. Her urine culture from September 15 showed equal or greater than 100,000 Escherichia coli bacteria. Despite this active infection and her severe kidney condition, the nursing assistant cleaning her failed to separate her labia during perineal care.
Two CNAs placed the woman on a bedpan and removed it after she voided. One assistant cleansed her groin and inner thighs, wiped the perineal area front to back, then rinsed and dried all areas. But the critical step of separating the labia was omitted entirely before the staff turned her to clean her buttocks and rectal area.
The woman's care plan, dating to 2019, specifically required incontinence care after each episode according to facility policy. Her medical record showed she was at risk for skin injury related to immobility, obesity, and bowel and bladder incontinence.
At 10:59 AM that same day, inspectors watched another nursing assistant provide similarly incomplete care to a second resident. The CNA cleansed the woman's left groin, then right groin, took a soaped cloth and wiped the front of her perineal area, then rinsed and dried. Again, no separation of the labia.
This resident was always incontinent according to her assessment records and cognitively intact. Her care plan from August documented she was at risk for impaired skin due to mobility issues and incontinence, with interventions requiring incontinence care after each episode per facility protocol.
The third incident occurred during afternoon care at 1:27 PM. After one nursing assistant cleansed the resident's front, another turned her to the left side. The first assistant then used a soaped cloth to clean the buttocks, followed by a clean soaped cloth for the rectal area.
But this time, the cleaning went in the wrong direction entirely.
The assistant cleansed from rectum to perineal area, then used a clean wet cloth to rinse from rectal area to perineal area. The facility's own policy explicitly states cleaning should go from front to back, not back to front, to prevent bacteria from the rectal area contaminating the urinary tract.
This resident was always incontinent and required extensive assistance with toileting, according to her December 2021 care plan.
When questioned about proper technique, one nursing assistant acknowledged the correct procedure. "When providing peri care cleansing is to be done going from the front to the back," the CNA told inspectors at 1:55 PM on September 17.
The Director of Nursing agreed staff should provide complete care. "She would expect staff to provide complete peri care and incontinent care," she told inspectors the following morning.
The facility's own Perineal Care Procedure, though undated, clearly outlines the steps staff skipped. The policy states the purpose is "to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition."
For female residents, the procedure specifies: "wash perineal area, wiping from front to back; separate labia and wash downward front to back." It also requires washing "the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks."
The violations occurred despite all three residents being cognitively intact, meaning they were aware of the inadequate care they received. Two of the three residents were described as always incontinent, making proper hygiene technique essential for preventing recurring infections.
Federal inspectors found the facility failed to provide complete incontinence and perineal care to three of the four residents they reviewed for incontinence care. The violations were classified as causing minimal harm or potential for actual harm to few residents.
The incomplete care puts vulnerable residents at increased risk for urinary tract infections, skin breakdown, and other complications. For the resident already fighting an E. coli infection with severely compromised kidneys, the inadequate hygiene could worsen her condition or lead to recurring infections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gillespie Health & Rehab Ctr from 2025-09-18 including all violations, facility responses, and corrective action plans.