Resident #6, who scored just 2 out of 15 on a cognitive assessment indicating severely impaired mental status, was wheeled to the TV lobby after breakfast on October 23 and left there until lunchtime. The man has Alzheimer's disease, kidney disease, and requires maximum assistance with nearly every daily activity.
Staff brought him to the lobby area at 8:46 AM and he remained in exactly the same position until 11:00 AM, when an aide finally moved him to the dining room for lunch. During those two hours and 14 minutes, no staff member repositioned him or checked his incontinence briefs.
The resident's care plan specifically requires staff to check him multiple times per shift and provide cleaning "with each incontinence episode." A facility policy from 2013 mandates that wheelchair-bound residents be repositioned every hour.
Between 11:12 AM and 11:27 AM, five certified nursing aides and three licensed practical nurses told inspectors they had not helped the resident with repositioning or toileting after breakfast. Electronic health records showed his last documented care occurred at 8:52 AM and 8:53 AM, right around breakfast time.
One aide, Staff O, later claimed she had provided incontinence care and repositioning at 9:40 AM with help from two other staff members. But she said she documents care after completing it, and the times in the computer system were from before breakfast.
The resident requires two-person assistance and a mechanical lift for all transfers. His medical assessment shows he needs maximum help with oral hygiene, bathing, dressing, and rolling over in bed. He is completely dependent for mobility and is "always incontinent of bowel and bladder."
His diagnoses include renal disease, Alzheimer's disease, non-Alzheimer's dementia, and kidney and ureter disorders. The care plan revision from October 1 emphasizes his complete dependence on staff for toilet use and transfers.
At 2:46 PM, after inspectors documented the extended period without care, the Director of Nursing acknowledged the failure. She stated that staff should have taken the resident to his room after breakfast to perform incontinence care and repositioning.
The violation occurred during a complaint investigation at the 69-bed facility. Inspectors conducted continuous observation to document exactly how long the vulnerable resident went without basic care that his condition requires multiple times each shift.
Federal regulations require nursing homes to provide assistance with activities of daily living for residents who cannot perform them independently. The inspection found Ramsey Village failed this requirement for a man whose severe cognitive impairment and physical dependencies make him completely reliant on staff attention.
The resident's Brief Interview for Mental Status score of 2 out of 15 indicates he cannot advocate for himself or communicate his needs effectively. His complete incontinence means extended periods without care create risks for skin breakdown and infection.
Staff members' conflicting accounts about who provided care and when highlight gaps in the facility's monitoring systems. While one aide claimed to have helped the resident at 9:40 AM, five other staff members confirmed no care occurred after breakfast, and electronic records showed no documentation of mid-morning assistance.
The facility's own repositioning policy establishes hourly care as the standard for wheelchair-bound residents. The resident's individualized care plan goes further, requiring checks multiple times per shift specifically because of his incontinence issues.
Inspectors rated the violation as causing minimal harm or potential for actual harm, affecting few residents. But for Resident #6, the two-plus hours without repositioning or incontinence care represented a complete breakdown in the basic assistance his severe disabilities require around the clock.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ramsey Village from 2025-10-23 including all violations, facility responses, and corrective action plans.