Federal inspectors found that CNA H did not retract the foreskin of Resident #11 during incontinence care on November 20, despite facility policy requiring it. The resident has been at Jourdanton Nursing and Rehabilitation for over a decade, first admitted in December 2014 and readmitted in October 2020.
Resident #11 lives with vascular dementia, schizoaffective disorder, high blood pressure, type 2 diabetes, and irritable bowel syndrome. His cognitive assessment showed moderate impairment. Medical records indicate he is always incontinent of both bowel and bladder.
The facility's own care plan, dated September 26, identified skin integrity problems related to scrotal excoriation from moisture, friction, and incontinence. The plan called for maintaining proper incontinence care.
At 6:33 a.m. on November 20, inspectors observed CNA H providing incontinence care for Resident #11. The aide did not retract the resident's foreskin, failing to properly clean the head of his penis.
Two minutes later, inspectors interviewed CNA H. He admitted he did not retract the foreskin of Resident #11's penis. When asked why, the aide was unclear but acknowledged he knew he had to clean underneath it. He said he received incontinence care training from the director of nursing.
The director of nursing confirmed during a 7:11 a.m. interview that uncircumcised male residents require foreskin retraction for proper hygiene. She explained this prevents infection and skin breakdown. The director said she provided incontinence care training for staff within the year, with skills checked annually and as needed.
The facility's written policy on perineal care, dated 2024, explicitly states staff should "gently retract the foreskin if applicable."
The violation puts residents at risk for infection and skin breakdown, according to the inspection report. For Resident #11, who already has a history of scrotal excoriation from moisture and incontinence, proper hygiene becomes even more critical.
Federal regulations require nursing homes to provide appropriate care for residents who are incontinent of bowel or bladder, including proper catheter care and steps to prevent urinary tract infections. The facility failed to meet this standard for Resident #11.
The inspection was conducted in response to a complaint. Resident #11 represents one of the most vulnerable populations in nursing homes: residents with dementia who cannot advocate for themselves and depend entirely on staff for basic hygiene needs.
CNA H's admission that he knew proper procedure but failed to follow it highlights a gap between training and practice. Despite receiving instruction from the director of nursing and working under a written policy that clearly outlined requirements, the aide skipped a fundamental step in resident care.
The director of nursing's confirmation that she trains staff on proper incontinence care and checks skills annually makes the violation more concerning. The facility had systems in place to ensure proper care, but those systems failed when it mattered most.
Resident #11's complex medical conditions make him particularly susceptible to complications from improper hygiene. His diabetes increases infection risk, while his dementia prevents him from recognizing or communicating hygiene problems. His decade-long residency at the facility means staff have had extensive time to learn his specific care needs.
The inspection found the facility's failure affected few residents, but the potential for harm was significant. Urinary tract infections and skin breakdown can lead to serious complications, especially in elderly residents with multiple chronic conditions like Resident #11.
For a resident who cannot speak for himself, proper hygiene represents a basic dignity issue as well as a medical necessity. The two-minute gap between the observed violation and CNA H's admission suggests the aide understood he had done something wrong.
The facility's policy manual contained the correct procedures. Staff received training on those procedures. Yet when inspectors observed actual care, the most basic step was missing. Resident #11 continues to depend on staff who demonstrated they might not follow established protocols designed to protect his health and dignity.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Jourdanton Nursing and Rehabilitation from 2025-11-21 including all violations, facility responses, and corrective action plans.
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