The resident told inspectors on September 23 that he needed to be changed. When the unit supervisor checked his brief at 12:53 pm, she found it completely saturated with urine. The resident said he was last changed at 7:30 or 8:00 that morning.
His assigned certified nursing assistant admitted she last provided care at 9:00 am — nearly four hours earlier.
The resident suffers from hemiplegia and hemiparesis following a brain hemorrhage that affected his left dominant side. His care plan from March requires staff to provide incontinence care after each incontinent episode. Assessment records show he is always incontinent and completely dependent on staff for toileting hygiene.
Cognitive testing in June revealed a score of twelve, indicating moderate cognitive impairment.
When inspectors arrived, they observed the resident with yellow urine filling his brief. A large, irregular yellow ring stained his bed pad. A smaller ring had dried on his fitted sheet underneath.
"R3's bed pad is wet with urine," the nursing assistant told inspectors. "R3's sheet has a dried urine stain."
She acknowledged that residents should be changed every two hours and described this particular resident as "a heavy wetter."
The unit supervisor confirmed facility policy during the inspection. "Residents should be provided incontinence care every two hours and as needed," she said.
The Pearl of Hillside's own assessment documents from February state that "staff will ensure that incontinence care needs are met." The resident's individualized care plan specifically requires incontinence care after each episode.
Federal inspectors classified the violation as having minimal harm or potential for actual harm. The facility failed to provide required assistance with activities of daily living for a resident unable to perform them independently.
This case affected one of three residents reviewed for incontinence care during the complaint investigation.
The resident's medical condition makes him entirely dependent on nursing staff. His stroke left him with paralysis affecting his dominant side and cognitive impairment that limits his ability to communicate his needs effectively. Despite telling staff he needed to be changed, he remained in the saturated brief until the supervisor's intervention hours later.
The nursing assistant's admission that she last provided care at 9:00 am contradicts both facility policy and basic standards of dignified care. Her description of the resident as a "heavy wetter" suggests staff were aware of his frequent incontinence, making the four-hour gap in care more problematic.
The physical evidence inspectors documented — yellow urine filling the brief, wet bed padding, and dried stains on sheets — indicates the resident had been sitting in waste for an extended period. The staining pattern suggests multiple episodes of incontinence without intervention.
Facility policy requires incontinence care every two hours at minimum, with additional changes as needed. For a resident described as always incontinent and a heavy wetter, this represents a clear failure to meet established care standards.
The unit supervisor's immediate recognition of the problem during inspection suggests staff understood the requirements but failed to implement them. Her questioning of when the resident was last changed indicates this was not routine monitoring but a response to an obvious care failure.
The resident's vulnerability — stroke-related paralysis, cognitive impairment, and complete dependence for toileting — makes this violation particularly concerning. His ability to communicate that he needed changing demonstrates some awareness of his condition, yet staff failed to respond appropriately.
The dried urine stains on bedding suggest this was not an isolated incident but part of a pattern of delayed incontinence care. The resident remained in conditions that compromised his dignity and comfort while staff failed to meet basic care requirements.
Federal regulations require nursing homes to provide necessary care and services to help residents achieve their highest level of physical and mental well-being. Leaving a cognitively impaired stroke patient in urine-soaked conditions for over four hours falls short of this standard.
The nursing assistant's acknowledgment of proper procedures while simultaneously failing to follow them highlights the gap between facility policies and actual care delivery. Her admission that the resident should be changed every two hours, combined with her failure to do so, demonstrates the violation was not due to lack of knowledge but lack of implementation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pearl of Hillside,the from 2025-09-25 including all violations, facility responses, and corrective action plans.