Licensed Practical Nurse FFF was in the hallway with another staff member when they heard a bang from Resident 93's room on January 22. They found the resident on the floor surrounded by feces, clutching his ostomy bag. The resident reported he had been walking to the bathroom to empty the bag himself.
The resident was sent to the hospital with shoulder pain and altered cognitive status after the fall.
LPN FFF had not known the resident had an ostomy bag.
Neither did LPN O, who told inspectors on January 23 that he was unaware the resident had an ostomy and didn't know if the resident could care for it himself.
The resident's family had been providing the ostomy care that nursing staff should have been delivering. Family Member UUU told inspectors that he and another family member had been coming to the facility to help the resident with ostomy care because staff were not assisting with emptying the ostomy bag. This left the resident waiting for family visits to get basic care.
The family member had informed Director of Nursing D about these concerns but never heard back from facility staff.
Resident 93 has Crohn's disease and moderate cognitive impairment, according to his November 8 assessment. The ileostomy creates an opening in the abdominal wall that diverts waste from the small intestine into an external pouch.
During an interview on January 22, the resident said he felt shaky and didn't feel good, but couldn't answer specific questions about his medical needs.
The facility's own policy, dated July 1, 2025, requires ostomy care to be provided by licensed nurses under physician orders. The orders should specify the type of ostomy, frequency of pouch changes, and equipment type.
Resident 93 had no physician orders for ostomy care.
The resident also had no baseline assessment or comprehensive care plan directing staff on his ostomy care needs, despite living at the facility since at least November.
Director of Nursing C acknowledged during a January 29 interview that staff should assist residents with colostomy care and be informed when residents have ostomies. She expected residents to have care plans indicating ostomy care interventions and physician orders for such care.
She also expected DON D to have contacted the resident or family after being informed of care concerns.
None of these expectations were met.
The facility's policy states that ostomy care should minimize residents' skin exposure to fecal matter, but the inspection found the opposite occurred. The resident's attempt to manage his ileostomy independently resulted in him falling and being covered in waste.
The policy also emphasizes allowing residents to perform as much care as possible according to their goals and preferences. However, with moderate cognitive impairment and no staff support or physician orders, Resident 93 was left to manage complex medical care beyond his capabilities.
Grove at Kirkwood houses 91 residents. Federal inspectors reviewed 21 resident cases during their January 29 complaint investigation and found this ostomy care failure affected few residents with minimal harm.
The resident's fall illustrates the consequences when basic nursing care breaks down. Staff unfamiliarity with residents' medical devices can create dangerous situations, particularly for cognitively impaired patients who cannot advocate for themselves.
Family Member UUU's unreturned concerns to nursing leadership suggest communication failures beyond the direct care level. The family stepped in to provide medical care that licensed nurses should have been delivering under proper physician supervision.
The inspection revealed a facility where nursing staff remained unaware of a resident's major medical needs for months, leaving family members to bridge critical care gaps while the resident struggled alone with tasks requiring professional assistance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grove At Kirkwood, The from 2026-01-29 including all violations, facility responses, and corrective action plans.