The incident at Avenue Care and Rehabilitation Center prompted a federal complaint investigation that found the facility failed to provide timely incontinence care to Resident 84, leaving her soaked through to the mattress on multiple occasions.
The resident's daughter confronted staff about the conditions. "The bed was so saturated it was a puddle of pee," she told investigators. "The nurse said to put a cover over it."
She took five photographs as evidence. The images showed a mattress with a folded blanket, a saturated adult brief, and three pictures of soaked bedding.
The next morning brought the same problem. The daughter found her mother again lying in a saturated bed and called Assistant Director of Nursing 355. They scheduled a meeting for Monday morning.
"I showed her the pictures," the daughter said.
Interim Director of Nursing 355, who had been promoted since the incident, confirmed she met with the family and viewed the same five photographs. "It was not the level of care they strive for," she acknowledged to investigators.
The nursing director identified Licensed Practical Nurse 384 as the staff member working that day. According to the interim director, LPN 384 claimed she was going to get supplies to change the resident "but by the time she did, the family had already changed her."
The family had to wait for supplies to clean their loved one themselves.
"I have had other families and residents express concerns about not getting checked or changed timely," the interim director admitted. "I am sure the resident was not changed timely. I saw the pictures, I spoke to the family, I spoke to the staff. It was clear she was not changed timely."
Facility policy requires residents to be checked and changed every two hours and as needed.
Certified Nursing Assistant 309, who regularly cared for Resident 84, revealed the scope of the problem during her interview. The resident was continent but needed quick assistance when she requested help.
"If we were busy we would ask her to wait," CNA 309 explained. "She could hold it for about five minutes but not much longer or she would be incontinent. That's why we put a brief on her."
The pattern continued repeatedly. "Sometimes I came in in the mornings, she was soaked, saturated to the mattress," the nursing assistant said.
Licensed Practical Nurse 393, who had admitted Resident 84 to the facility, confirmed the resident required assistance from one staff member to use the bathroom and was incontinent at times.
The interim director told investigators that all staff received education after the incident, but nothing was documented in writing.
Federal inspectors found the facility violated regulations requiring appropriate treatment and services to maintain residents' ability to carry out activities of daily living, including elimination and hygiene needs.
Avenue Care's own policy promises to "humanize and individualize each resident's quality of life" and provide "person-centered" care that honors "each resident's preferences, choices, values and beliefs."
The policy specifically requires the facility to provide care for hygiene and elimination needs, stating that residents unable to carry out activities of daily living "will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene."
The violation represents continued noncompliance from a previous survey conducted in August. The October complaint investigation, numbered 2648929, documented what federal regulators classified as "minimal harm or potential for actual harm" affecting some residents.
The resident's daughter had to become her own advocate, documenting the neglect with photographs and demanding meetings with nursing leadership to address conditions that left her mother lying in her own waste while staff suggested covering the problem with a blanket.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avenue Care and Rehabilitation Center, The from 2025-10-29 including all violations, facility responses, and corrective action plans.
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