The incident at Accura Healthcare of Cherokee came to light when the resident's daughter complained to administrators in late October. Staff members told inspectors during an August 27 meeting that two certified nursing assistants had "made Resident #1 urinate in her bed" and "moved the call light out of Resident #1's reach."
The Director of Nursing confirmed she received the complaint from the resident's daughter on October 23 or 24. "The DON revealed it is a concern if staff were telling residents to urinate themselves, and this would be a dignity issue," inspectors wrote.
But when administrators tried to investigate, night shift staff refused to cooperate.
"The DON came in the next nightshift, and no staff could give her an answer as to what happened," the inspection report states. "None of the nightshift staff would admit it was them."
One nursing assistant, identified as Staff B, told inspectors she had heard through a day shift worker that another employee "had told a resident to go ahead and urinate on themselves and that they would clean that resident up afterward." Staff B said the incident happened during a shift when both were working, but she didn't witness it directly.
Staff B herself has drawn multiple complaints about her treatment of residents. The Director of Nursing told inspectors "most of the complaints on Staff B are related to poor bedside manners" and that "she has talked with Staff B multiple times about how Staff B is very dry, and direct when talking to the residents."
The nursing director described Staff B as having "gruffness" and being "rough around the edges" when interacting with residents.
During the August staff meeting, administrators addressed broader problems with night shift care. The Director of Nursing said "there were issues with the night shift not getting residents up as often as they should."
The administrator confirmed she attended the August 27 meeting where the call light incident was discussed. She told inspectors her understanding was that "a staff member did not give the call light to a resident for them to use" and that staff had "encouraged a resident to be incontinent, and that staff would come back and clean them up."
Despite the serious nature of the allegations, the facility never filed a formal grievance report about the incident.
The resident's family member confirmed to inspectors that their loved one had told them about "being told to urinate in the bed, and taking the call lights away from her." The family member said the facility "addressed it with the staff, and it was taken care of" and that "it had never happened again."
Federal inspectors noted that both the Director of Nursing and administrator stated "their expectation would be for residents to be treated with dignity and respect at all times." The facility's own policy on promoting and maintaining resident dignity, dated January 30, 2024, requires that "all staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights."
Call lights serve as a critical safety tool for nursing home residents, allowing them to summon help for toileting assistance, medical emergencies, or other needs. Removing or withholding access to call lights can leave vulnerable residents unable to get help when needed.
The inspection found the facility violated federal requirements for treating residents with dignity and ensuring their rights are protected. Inspectors determined the violation caused minimal harm or potential for actual harm to a few residents.
The investigation revealed a pattern of communication problems between staff and management. When the Director of Nursing tried to determine which employees were involved in the incident, she found that staff members either couldn't or wouldn't provide information about what had happened to the resident.
One staff member, identified as Staff E, confirmed during interviews that the incident involving Resident #1 was specifically discussed during the August 27 all-staff meeting, where it was revealed that the two nursing assistants had both encouraged the resident to urinate in bed and moved her call light away.
The facility's inability to identify the specific staff members responsible for the incident, despite multiple employees knowing about it, raised questions about accountability and reporting procedures within the nursing home.
Federal regulations require nursing homes to ensure residents are treated with dignity and that their rights are protected at all times. The alleged actions of telling a resident to urinate in bed while removing their ability to call for proper assistance represents a fundamental violation of those protections.
The resident's family member indicated they were satisfied with how the facility ultimately handled their complaint, though the investigation revealed ongoing concerns about staff behavior and supervision during night shifts.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of Cherokee, LLC from 2025-10-30 including all violations, facility responses, and corrective action plans.
Additional Resources
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