Federal inspectors observed the neglect on November 10 during a complaint investigation at the 108-bed facility. The patient, identified as Resident #28, had been admitted in June 2015 following a stroke that left him with weakness on his left side, muscle weakness, and dementia.
The resident was completely dependent on staff for toileting and incontinent of both bowel and bladder. His care plan specifically required staff to apply protective barrier ointment after each incontinence episode to prevent skin breakdown. A physician's order mandated cleansing his buttocks with soap and water and applying thick zinc barrier cream every shift and as needed.
When inspectors arrived at 11:39 a.m., they found the resident lying on two bath blankets and a fitted sheet soaked with large amounts of dried urine and other debris. A strong odor of urine emanated from his bed and linens.
Certified Nursing Assistant #385 told inspectors she had provided incontinence care to the resident approximately one hour earlier. She acknowledged that the resident sometimes developed reddened areas on his buttocks and tailbone that required barrier cream application.
But when inspectors examined the resident, they found no evidence that any barrier cream had been applied. Large amounts of dried stool remained caked in the creases of his buttocks.
The nursing assistant confirmed what inspectors could see plainly. She admitted she had not applied the required barrier cream after her last round of incontinence care. She also claimed she had not noticed the soiled bedding when she supposedly provided care an hour before.
The resident's medical records painted a picture of profound vulnerability. His most recent assessment noted that he was "rarely/never understood" due to his cognitive impairment. He had been living at Diplomat Healthcare for over a decade, entirely dependent on staff for his most basic needs.
Facility policy required staff to turn patients on their side and wash the rectal area, working outward to include the buttocks. The policy specifically stated that moisture barriers should be applied when included in care plans.
The November 4 care plan update explicitly listed interventions to assist with incontinence care as needed and to apply skin barrier ointment after incontinence episodes. The resident was documented as being at risk for skin breakdown.
Despite these clear requirements, CNA #385 had left the resident lying in conditions that violated both physician orders and facility policy. The dried stool suggested the neglect had persisted for significantly longer than the hour she claimed since her last care.
The inspection was conducted as part of three separate complaint investigations. Federal regulators cited the facility for failing to provide appropriate incontinence care, noting minimal harm or potential for actual harm to residents.
The resident's decade-long stay at Diplomat Healthcare began after his stroke robbed him of his independence and cognitive abilities. Now 85 years old, he relied entirely on nursing assistants like CNA #385 for dignity in his most vulnerable moments.
Instead, inspectors found him lying in his own waste, his skin at risk of breakdown from prolonged exposure to urine and feces. The nursing assistant's admission that she hadn't seen the soiled linens during her previous care raised questions about whether any meaningful cleaning had occurred at all.
The facility's own policy manual outlined the proper steps for incontinence care. CNA #385 knew the resident needed barrier cream applied. She knew his history of developing reddened, irritated skin. She knew the physician had ordered protective ointment every shift.
Yet when federal inspectors arrived unannounced on that November morning, they found a stroke patient with dementia abandoned in conditions that no human being should endure. The strong smell of urine filled his room. Dried waste clung to his body.
The resident couldn't advocate for himself. His dementia meant he was rarely understood when he tried to communicate. His physical limitations from the stroke meant he couldn't clean himself or change his position.
He depended entirely on the compassion and competence of his caregivers. On November 10, that trust was betrayed by a nursing assistant who claimed to provide care while leaving him lying in his own filth.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diplomat Healthcare from 2025-11-25 including all violations, facility responses, and corrective action plans.