The violation occurred at 5:24 a.m. on December 23 at Claymont Health and Rehabilitation, where federal inspectors were conducting a complaint investigation. Certified Nursing Assistant #111 provided incontinence care to Resident #17, then placed a fresh brief and pulled his pants up to his knees without applying the required moisture barrier ointment.
Resident #17 had been admitted to the 52-bed facility on January 13, 2025. His medical record showed diagnoses of major depression disorder, dementia, chronic obstructive pulmonary disease, and difficulty swallowing. He was frequently incontinent of bladder and occasionally incontinent of bowel, requiring partial to moderate assistance with toileting.
His physician had ordered house moisture barrier ointment to be applied to his perineum area, buttocks, and tailbone after each incontinent episode. The order was written on his admission date and remained active throughout his stay.
When inspectors interviewed CNA #111 thirty minutes after the observed incident, she confirmed she had not applied the incontinence cream to the resident's bottom after the episode. The facility's Director of Nursing later verified that the nursing assistant had failed to follow the doctor's orders.
The facility's own policy, dated September 2017, outlined detailed procedures for incontinence care designed to maintain skin integrity, prevent breakdown, control odor, and preserve resident comfort and self-esteem. The protocol required staff to cleanse the resident with mild cleanser, pat dry while avoiding friction, and apply protective barrier ointment according to product directions.
Proper incontinence care becomes critical for residents like #17, whose combination of frequent incontinence and underlying health conditions creates heightened risk for complications. Barrier creams form a protective layer between skin and moisture, preventing the chemical burns and infections that can develop when urine and feces remain in contact with delicate tissue.
The violation represented a breakdown in basic care protocols. Staff members are required to follow physician orders precisely, particularly for vulnerable residents who cannot advocate for themselves or recognize when care is incomplete.
Federal inspectors noted the deficiency affected one resident out of four they reviewed for incontinence care during their investigation. The finding emerged from a complaint filed against the facility, though the specific nature of the original complaint was not detailed in the inspection report.
For residents with dementia like #17, consistent application of protective measures becomes even more essential. These patients often cannot communicate discomfort or recognize early signs of skin problems, making prevention through proper care protocols their primary defense against serious complications.
The nursing assistant's failure to follow the physician's order violated federal regulations requiring facilities to provide appropriate treatment and care according to medical orders and resident preferences. While inspectors classified the violation as causing minimal harm or potential for actual harm, the incident highlighted gaps in care delivery that could escalate into serious medical problems.
Claymont Health and Rehabilitation was required to submit a plan of correction addressing how they would ensure proper incontinence care protocols are followed consistently. The facility had 14 days from receiving the inspection report to make their correction plan publicly available.
The December 23 inspection was completed as part of complaint investigation number 2619625. Federal regulations require nursing homes to follow physician orders precisely and maintain protocols that protect resident health and dignity, particularly for vulnerable populations who depend entirely on staff for basic care needs.
Resident #17 remained at the facility following the inspection, with his care needs requiring continued attention to prevent the skin breakdown and infections that proper barrier cream application is designed to prevent.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Claymont Health and Rehabilitation from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
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