Resident #6 told inspectors on September 30 that her brief had last been changed the night before. She said she was wet. When inspectors observed her at 11:44 AM, they found her lying on bed linens soaked with urine.
The same morning, inspectors watched certified nursing assistant CNA D provide incontinence care to two residents. Both were "heavily soaked in urine" when he arrived to change them.
During care for Resident #5 at noon, CNA D failed to cleanse the resident's perineal area entirely. He cleaned only her abdominal folds before turning her to clean her buttocks, leaving the labia majora unwashed despite the resident being heavily soaked.
Fifteen minutes later, inspectors observed the same assistant caring for Resident #6. Again, the resident was heavily soaked in urine. Her brief, draw sheet, and mattress cover were all saturated. CNA D again failed to cleanse the resident's perineal area, cleaning only abdominal folds before repositioning her.
The resident had also had a bowel movement. After cleaning fecal matter from her body, CNA D did not change his gloves or wash his hands before continuing the procedure.
When inspectors interviewed CNA D at 12:24 PM, he admitted he had last checked on residents during shift change from the night crew. He said he had changed Resident #6 around 7:15 AM before breakfast but had not changed Resident #5 at all during his shift.
CNA D acknowledged he was supposed to perform incontinence rounds every two hours and as needed. He said he was "busy with other residents" and had not completed the required checks. He told inspectors that failure to change residents every two hours "could lead to skin breakdown."
The day shift nurse, LVN C, told inspectors staff were required to perform incontinence rounds every two hours. She was supposed to monitor nursing assistants to ensure they completed these rounds but could not recall when she had last done monitoring rounds herself.
Both LVN C and CNA D said they had received training on incontinence care procedures, though CNA D could not remember when the training occurred.
The facility's Assistant Director of Nursing said she expected staff to perform rounds every two hours and as needed. Nurses were responsible for monitoring nursing assistants during their shifts, she said. She acknowledged that failing to perform two-hour rounds "could lead to skin issues and infections."
The Director of Nursing repeated the same expectations and risks. She said nurses should monitor nursing assistants "by performing rounds behind the CNAs." She told inspectors she had conducted training with staff on providing incontinence care every two hours.
However, facility training records from August 29 showed the in-service on perineal care covered procedures and guidelines but did not address the requirement for incontinence care every two hours.
The facility's perineal care policy, revised in April 2024, states only that "staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection." The policy does not specify timing requirements for incontinence checks.
LVN C told inspectors that leaving residents wet for extended periods predisposes them to "skin irritation and urinary tract infections."
The violations occurred despite facility policies requiring proper incontinence care and staff training on procedures. Federal regulations require nursing homes to provide necessary care to prevent urinary tract infections and maintain residents' dignity and comfort.
The inspection found that some residents were affected by the deficient care practices. Inspectors classified the violations as causing minimal harm or potential for actual harm to residents.
Both residents observed by inspectors were left in conditions that facility staff acknowledged could cause medical complications. The failure to properly cleanse residents' perineal areas during incontinence care compounds the risk of infection from prolonged exposure to urine and feces.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Williamsburg Village Healthcare Campus from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
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