Federal inspectors found Atlas Healthcare at Daughters of Miriam violated incontinence care standards during an October 30 complaint investigation. The facility's own director of nursing told inspectors that double diapers should not be used on cognitively impaired residents because of infection and skin injury risks.
Yet staff had put Resident #2 in double incontinence briefs.
The director of nursing explained the facility's policy during an 11:43 AM interview. She said the nursing home allows double diapers when residents specifically request them, naming two residents on a different floor who had made such requests. She emphasized that staff must be notified of any such preference and the request documented in the care plan.
But she made clear the practice had limits.
"For cognitively impaired residents, two incontinence briefs were not used," the director told inspectors. When asked why, she explained double briefs "would increase the risk for skin impairment and cause a urinary tract infection."
The director did not name Resident #2 as someone who had requested double briefs.
At 12:14 PM, inspectors notified both the director of nursing and the licensed nursing home administrator that they had observed Resident #2 wearing double incontinence briefs. The director responded that staff had added the double brief preference to the resident's care plan that day.
The timing raised questions about the facility's documentation practices.
Records showed significant gaps in tracking Resident #2's incontinence care throughout October. The facility's CNA Documentation Survey Report, which tracks nursing assistant interventions and accountability, showed the resident coded as incontinent most days of the month. But three shifts were left completely blank: day shifts on October 7 and October 27, and the night shift on October 11.
More troubling, the resident's care plan contained contradictory information about their continence status.
At 1:30 PM, inspectors pressed the director and administrator about the documentation gaps and inaccurate care plan. The director said she had just interviewed Resident #2, who told her they wanted the double brief "because they did not want the one brief to leak."
But when inspectors asked about the care plan indicating the resident was continent and used a bedpan or urinal, the director acknowledged the contradiction. She said Resident #2 "was continent in the past and that the CP needed to be updated."
The director confirmed the double brief preference had been added to the care plan that day.
The sequence of events suggested the facility had been providing care that contradicted both its own safety policies and the resident's documented care plan. Staff were using double incontinence briefs on a cognitively impaired resident while the care plan still listed them as continent and using a bedpan or urinal.
The director's own statements highlighted the medical risks of the practice she found staff implementing. She had clearly articulated why double briefs posed dangers for cognitively impaired residents, citing increased infection risk and potential skin breakdown.
Yet the facility appeared to have no system in place to ensure its safety policies were followed or that care plans accurately reflected residents' actual conditions and needs.
The inspection revealed a nursing home where staff practices, safety policies, and care plan documentation existed in separate spheres with little coordination. A resident received care that the director of nursing herself described as medically inappropriate, while official records suggested they needed no incontinence assistance at all.
Neither the licensed nursing home administrator nor the director of nursing provided additional information when given the opportunity.
The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Atlas Healthcare At Daughters of Miriam from 2025-10-30 including all violations, facility responses, and corrective action plans.
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