Resident #2 was incontinent of urine on at least one shift for twelve out of twenty-one days tracked in September, according to federal inspectors who reviewed the facility's bladder flowsheets. Four additional days had no documentation recorded for the evening shift at all.
The resident's admission nursing assessment identified him as incontinent of bowel and bladder when he arrived at the facility. His diagnoses included dementia and benign prostatic hyperplasia. A quarterly assessment showed he had poor memory recall deficits and required extensive assistance from one staff member for toilet use.
Yet the facility's baseline care plan given to the resident's representative on June 23 contained no interventions to address his incontinence. The only mention appeared under a skin breakdown prevention plan that directed staff to "apply barrier cream with incontinent care."
The October 3 fall happened when the resident attempted to go to the bathroom without help. Although staff updated his fall risk care plan five days later with an intervention to "offer and assist with toileting at the beginning of third shift," they still failed to create any plan addressing his underlying incontinence problem.
The Corporate Nurse confirmed during an interview that the care plan contained no information about the resident's incontinence except for the barrier cream notation under skin care. This violated the facility's own policy requiring comprehensive and individualized care plans that include problem statements, measurable goals, and specific interventions.
The resident's quarterly assessment revealed the scope of his needs. He scored eight out of fifteen on a mental status test, indicating significant cognitive impairment. He was occasionally incontinent of urine and frequently incontinent of bowel. He required limited assistance from one person for transfers but extensive help for toilet use.
Federal inspectors found the facility's care planning policy directed that plans "will guide caregivers to assist residents to achieve or maintain their highest practical level of wellbeing." The policy required care plans to include problem statements, reasonable and measurable goals, interventions to achieve those goals, and identification of which staff disciplines would carry out the interventions.
None of this existed for the resident's incontinence management.
The inspection revealed broader documentation gaps. Four days during the September tracking period showed no entries at all for the 3-11 PM shift on bladder flowsheets. This left staff on subsequent shifts without information about the resident's condition or needs during those hours.
The resident's combination of dementia, prostate problems, and mobility limitations created a complex care situation. His cognitive impairment meant he couldn't reliably remember or communicate his need to use the bathroom. His physical condition required staff assistance for safe toilet use. Yet the facility treated his incontinence as a side effect requiring only skin protection rather than a primary care need demanding intervention.
The fall at 12:20 AM illustrated the consequences. The resident attempted independent bathroom access because no systematic plan existed to anticipate and address his needs. Only after the incident did staff add toileting assistance to his care plan, and even then only for the beginning of the overnight shift.
Federal regulations require nursing homes to develop complete care plans addressing all resident needs with specific, measurable interventions. The inspection found Ledgecrest failed this basic requirement for a vulnerable resident whose combination of cognitive and physical impairments demanded comprehensive planning.
The Corporate Nurse's acknowledgment during the October 9 interview confirmed what inspectors documented through record review. Despite months of evidence showing regular incontinence episodes and the resident's October fall while seeking bathroom access, the facility had never developed appropriate interventions to address his underlying condition.
The violation received a minimal harm designation affecting few residents, but highlighted fundamental gaps in care planning that left a dementia patient without essential support for a basic human need.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ledgecrest Health Care Center from 2025-11-21 including all violations, facility responses, and corrective action plans.
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