The September incident at Regency at Troy involved a resident who had been hospitalized multiple times for serious kidney and urinary tract infections. When inspectors found them at 9:59 AM on September 24, the resident explained they were "always wet and sitting in wet diapers for hours."
"This is why I always get infections," the resident told inspectors.
The resident said their brief had last been changed by the night shift at 6 AM and they hadn't seen their assigned nursing assistant for the day. They had been lying in the wet brief "for some time."
When inspectors interviewed the assigned nursing assistant at 10:24 AM, the aide confirmed they were responsible for the resident but had been on duty for three and a half hours without checking on them. The aide was assigned to thirteen residents and admitted to being late that day, clocking in at 8 AM instead of 7 AM.
The nursing assistant said they would "check in on the resident now."
One minute later, inspectors watched as the aide removed the resident's brief. It was soaked with urine. Dried urine stains covered the bed sheets, though the bed pad appeared dry. The aide said they would change all the bedding.
The resident's medical history revealed the severe consequences of poor incontinence care. They had been admitted to Regency at Troy with acute pyelonephritis, a kidney infection, along with acute kidney failure and urine retention requiring assistance with personal care.
Recent hospitalizations told a troubling story. The resident was hospitalized for sepsis secondary to a urinary tract infection. Another recent admission involved pyelonephritis, another kidney infection.
Facility policy required "incontinence care provided timely according to each resident's needs" and assistance "to maintain good grooming and personal hygiene." The Director of Nursing acknowledged that bowel and bladder checks should occur every two hours and as needed for incontinent residents.
The nursing assistant's timesheet revealed they were marked "Tardy" on September 24, clocking in an hour late.
When inspectors interviewed the Director of Nursing at 12:58 PM, she said she would need to check on who covered the resident from 7 AM to 8 AM when the assigned aide was absent. She acknowledged the expectation for two-hour incontinence checks.
The next day, the Director of Nursing admitted there had been "miscommunication regarding the CNA coverage" but said an aide was assigned to the resident until the regular aide arrived. She acknowledged the concern that the resident hadn't been checked for incontinence from 6 AM until 10:30 AM, when the surveyor approached the nursing assistant.
The Director said she had scheduled a meeting with aides for the following week "to discuss further education and expectations moving forward."
No additional explanation was provided by the end of the inspection.
The violation represented a breakdown in basic care for a vulnerable resident whose medical conditions made timely incontinence care critical. The resident's own words captured the human cost: sitting wet for hours, developing repeated infections, cycling in and out of hospitals.
For someone with acute kidney failure and a history of serious urinary tract infections, prolonged exposure to urine creates exactly the conditions that lead to the hospitalizations they described. The facility's two-hour policy existed precisely to prevent such complications.
The nursing assistant's late arrival and failure to check on assigned residents for hours illustrated systemic problems beyond individual negligence. Thirteen residents assigned to one aide, late arrivals without adequate coverage, and confusion about who was responsible for basic care.
The resident remained vulnerable to the cycle they described to inspectors: wet diapers, infections, hospitalizations, and return to a facility where the same problems persisted.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Regency At Troy from 2025-11-20 including all violations, facility responses, and corrective action plans.