The resident at Cityview Nursing and Rehabilitation Center told inspectors on January 29 that his bedding had not been changed since the night before. The draw sheet under him was saturated with dried urine, indicated by its brown color.
"He stated no one had checked on him that morning," inspectors wrote.
The patient, identified in records as a male with intestinal cancer that had spread throughout his body, also had a mass on his left kidney requiring a drainage tube and acute kidney failure. His care plan noted he was incontinent of bowel and bladder and was taking diuretics to remove excess fluid.
Despite his medical complexity, the resident's cognitive assessment showed he was mentally intact. But he told inspectors he "did not realize the bedding was wet, and was not sure when it happened, so he had not notified staff."
When inspectors interviewed the certified nursing assistant assigned to his care five minutes later, she admitted she "had not checked on Resident #1 yet."
"She had been busy with other residents," the report stated. "She was unaware the resident was incontinent of urine."
The CNA told inspectors she did not feel overworked because there were other nursing assistants working the hall.
The assistant director of nursing had a different assessment when inspectors spoke with him at 11:19 AM.
"There was no reason Resident #1 should have been left on dirty linen," he told inspectors. "The night shift should have noticed it and changed it, or CNA-A should have noted it earlier in her shift when she made rounds on all her residents."
The administrator said his expectation was for CNAs and nurses to check on all residents at the beginning of their shifts to assess their needs. He acknowledged the medical risk: "The risk of a resident lying in urine-soaked linen could result in skin breakdown or irritation."
Inspectors examined the resident's skin immediately after discovering the neglect. At 11:25 AM, they found no skin breakdown or wounds on his peri area and buttocks, though some redness was present from lying on his back.
The facility's care plan from December 17 had specifically identified this resident's vulnerability. It noted his "ADL self-care deficit related to functional decline" and documented that he was "dependent on staff for his toileting hygiene."
His admission assessment from December 5 showed he was only "occasionally incontinent of urine," making the overnight saturation of his bedding a significant change that should have triggered immediate attention.
Other residents on the same hall told inspectors they had no complaints about dirty linens not being changed. They said staff checked on them regularly and their needs were being met.
But for this cancer patient, the system failed completely. From evening until nearly noon the next day, he lay in conditions that his own administrator acknowledged could cause skin breakdown.
The facility's Activities of Daily Living policy, dated May 26, 2023, addressed bathing, dressing, grooming, oral care, and toileting. But inspectors noted it "did not address changing linen specifically."
The inspection occurred during a complaint investigation, suggesting someone had reported concerns about conditions at the facility to federal regulators.
For a resident facing end-stage cancer, kidney failure, and complete dependence on staff for basic hygiene, lying in dried urine for hours represented more than a policy violation. As inspectors noted, the failure "could place the resident at risk of skin breakdown and decreased feelings of self-worth."
The man with intact cognition knew exactly what was happening to him. He just couldn't do anything about it until inspectors walked into his room that Wednesday morning and found him there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cityview Nursing and Rehabilitation Center from 2026-01-29 including all violations, facility responses, and corrective action plans.
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