Inadequate Incontinence and Nail Care Due to Staffing Shortages
Summary
The facility failed to provide routine and appropriate incontinence and nail care for dependent residents, as evidenced by multiple observations and interviews. A surveyor noted a strong odor of feces in a resident's room, and the resident reported that staff refused to assist with incontinence care. Another resident was observed with long, jagged fingernails coated with a black substance, despite their care plan indicating regular nail maintenance. During an incontinence care tour, several residents were found soaked in urine, and a CNA confirmed that residents were often left soiled due to staff shortages. Further investigation revealed that residents were sometimes left in double incontinence briefs, which were not changed in a timely manner. One resident was found covered in feces and urine, wearing two saturated briefs, and the CNA admitted that this was not the first occurrence. The facility had previously provided education against using double briefs, but staff shortages during certain shifts led to this practice. Interviews with CNAs confirmed that the facility was understaffed, with only two CNAs caring for 45 residents during the night shift, contributing to inadequate care. Additional interviews with residents and their representatives highlighted ongoing issues with incontinence care. One resident reported being left soiled for hours and stated that incontinence care was not provided during the night shift. Another resident's representative mentioned that the resident was left in a chair for an extended period without being changed. The facility's policy on Activities of Daily Living was reviewed, which stated that residents should receive necessary services to maintain hygiene, but the facility failed to adhere to this policy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
A resident who was dependent on staff for toileting and required a Hoyer lift, as documented on the MDS, did not receive timely incontinence care after activating the call bell. The resident reported requesting assistance, and a staff member acknowledged the call bell and stated they would notify a nurse aide, but no one arrived to provide care during an observation period lasting over an hour. This delay occurred despite facility policy requiring support for ADLs and the DON’s acknowledgement that a 15-minute wait for call bell response was considered too long.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
A resident with urinary incontinence, vascular dementia, and intellectual disability was repeatedly observed lying in bed with wet clothing and bedding and a strong urine odor, remaining wet for extended periods despite staff statements that residents were checked every two hours and that this resident had not refused care. On another occasion, the same resident was found with multiple soaked incontinence pads, a soaked brief, wet clothing, and wet bed linens, and the CNA initially did not check for incontinence when the resident was sleeping until prompted. The CNA reported routinely placing two incontinence briefs on the resident, and two briefs were observed in use, even though the care plan did not direct the use of more than one brief and there was no documentation of care refusals on the dates in question.
Surveyors found that several cognitively impaired, fully dependent residents did not receive basic ADL care, including shaving, nail care, face cleansing, and clean clothing. Residents were repeatedly observed with long facial whiskers, jagged and dirty fingernails, dried food on their faces, and soiled shirts, despite EMR, MDS, and care plans documenting the need for substantial to maximal staff assistance with personal hygiene. CNAs, an LPN, and administrative nursing staff all stated that residents were to be shaved on shower days, have nails trimmed and filed at least weekly, faces cleaned after meals, and clothing changed when dirty, but acknowledged these tasks did not always occur. These failures were inconsistent with the facility’s stated expectation and policy that residents be treated with dignity and respect.
Surveyors found that two cognitively intact residents, one with hypertension and one with dementia, did not receive showers on multiple days listed on their individualized shower schedules, despite one resident having previously filed a grievance about not getting showers and preferring showers over bed baths. Review of electronic and paper shower records showed several missed scheduled shower days for each resident, and documentation also noted that one resident refused a shower when it was offered outside his preferred time. These findings showed that staff did not consistently provide bathing on scheduled days in accordance with residents’ assessed needs, preferences, and stated rights.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs), specifically incontinence care, to a resident who was dependent on staff for these needs. Facility policy on ADL support, revised in April 2025, states that residents who are unable to carry out ADLs independently are to receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The resident’s Quarterly MDS dated March 4, 2026, documented that the resident required a Hoyer lift and was dependent on staff for showering/bathing and toileting. On the survey date, the resident reported during an interview at 11:12 a.m. that they required assistance with incontinence care and had activated their call bell at approximately 11:00 a.m. At 11:17 a.m., a staff member entered the room, acknowledged the call bell, and, upon being informed that the resident needed incontinence care, stated they would inform the nurse aide. By 11:35 a.m., when the interview concluded, no staff had come to provide the requested care. Continued observation from the nurses’ station between 11:35 a.m. and 12:03 p.m. showed that no staff responded to the resident’s call for incontinence assistance during that period. When questioned, the DON stated that a 15-minute wait time for call bell responses was considered too long, while the resident had been waiting for over an hour.
Plan Of Correction
Resident 1's call bell was responded to and incontinence care was provided on 4/14/2026. Facility wide audit of all residents who are dependent for toileting will be completed. Nursing staff will be educated on ASL policy. DON/Designee will complete ADL care audits daily x30 days then three times per week for 4 weeks to ensure proper ADL care is being provided. DON/Designee will report findings to QA Committee for review and recommendations.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Provide Timely Incontinence Care and Improper Use of Multiple Briefs
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and appropriate ADL assistance to a resident with urinary incontinence, as well as the inappropriate use of multiple incontinence briefs. On one date, surveyors observed the resident lying in bed with visibly wet pants and a noticeable urine odor in the room at midday. Over two hours later, the resident’s pants remained wet, with the wet area only beginning to fade. The CNA assigned to the resident stated he checked residents every two hours and had last checked this resident before lunch, and later reported he had just changed the resident and found him wet. The resident’s clinical record showed diagnoses including benign prostatic hyperplasia without lower urinary tract symptoms, vascular dementia, and intellectual disability, and the care plan directed staff to assist with routine toileting, check routinely for incontinence, provide incontinence care as needed, and encourage the resident to allow staff assistance when incontinent. On another date, the same resident was observed lying in bed with at least two incontinence pads under him and a visible ring of urine around him on the bed. Later observations that day showed an even darker ring of urine and an additional lighter, drying ring, with the resident remaining in the same position and the bed still wet. The CNA reported he had last changed the resident earlier that morning and that the resident had not refused care. During an ADL care observation, the CNA initially stopped at the door when he saw the resident sleeping and did not check for incontinence until prompted by the surveyor. When prompted to educate the resident and request permission to provide care, the resident got up and allowed the CNA to change him. At that time, the resident had two soaked incontinence pads, a soaked brief, a soaked red shirt, and soaked bed sheets, all of which were changed; the CNA then placed two incontinence briefs on the resident. The CNA stated he typically placed two briefs on this resident, although the care plan did not direct staff to use two briefs, and the Executive Director later confirmed staff should not place two briefs on a resident unless care planned. Documentation for the relevant dates did not show any refusals of care in the point-of-care records or progress notes, despite staff statements that the resident had not refused care.
Failure to Provide Basic ADL Hygiene and Grooming for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate activities of daily living (ADL) care, including shaving, nail care, face cleansing, and clothing hygiene, for multiple residents who were cognitively impaired and dependent on staff. One resident with dementia, documented as requiring substantial to maximal assistance with personal hygiene on the MDS, CAA, care plan, and EMR, was repeatedly observed on multiple days with long facial whiskers. CNAs and a licensed nurse stated that residents were supposed to be shaved on shower days, but acknowledged that this did not always occur. Administrative nursing staff also stated residents were to be shaved on shower days and as needed, consistent with the facility’s policy that residents have the right to be treated with dignity and respect. Another resident with severe cognitive impairment and dependent on staff for personal hygiene had a care plan directing staff to trim her fingernails weekly. She was observed on consecutive days sitting in a recliner with jagged, dirty fingernails. CNAs, a licensed nurse, and an administrative nurse all stated that residents’ fingernails were to be kept clean, smooth, and trimmed at least weekly, confirming that the observed condition did not meet facility expectations. The same facility policy on resident rights and dignity applied to this resident’s care. Additional residents with dementia or Alzheimer’s disease, all with MDS and care plan documentation showing moderate to severe cognitive impairment and dependence on staff for ADLs and personal hygiene, were observed with unshaven faces, dirty clothing, jagged and dirty fingernails, and dried food on the face. One resident was seen twice in the same day with an unshaven face and dried-on food debris on the front of his t-shirt, and another was observed on two days unshaven with jagged, dirty fingernails and dried food on his face around his mouth. Staff interviews confirmed that residents were supposed to be shaved on shower days, have their clothes changed when dirty, have their fingernails trimmed and filed weekly, and have their faces cleaned after meals as needed, but staff acknowledged these tasks did not always get done. These observations and statements show the facility did not follow its own care expectations and resident rights policy regarding dignity and respect.
Failure to Provide Scheduled Showers for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled bathing for residents who required staff assistance. For one resident with hypertension who was cognitively intact and required partial staff assistance for bathing, the clinical record showed a grievance had been filed stating she was not receiving her showers or having her hair washed. The grievance also noted that staff had been educated on her preference for a shower rather than a complete bed bath. Her shower schedule, updated on 4/1/26, listed Tuesday and Friday as her shower days, yet review of electronic and paper shower documentation showed she did not receive showers on several scheduled dates between 3/9/26 and 4/9/26, specifically on 3/10/26, 3/27/26, and 3/31/26. Another resident with dementia, who was cognitively intact per the admission MDS and required staff supervision during bathing, also did not receive showers on multiple scheduled days. His shower schedule, updated on 4/1/26, indicated Wednesday and Saturday as his shower days. Review of shower documentation from 3/11/26 to 4/9/26 showed missed showers on 3/14/26, 3/18/26, and 3/25/26. Documentation further indicated that this resident refused a shower on 4/8/26 because it was offered outside of his preferred shower time. The facility’s Residents Rights policy, revised 7/2023, stated that all staff members recognize the rights of residents at all times to enable personal dignity, well-being, and proper delivery of care, but the documented missed showers demonstrated that scheduled bathing was not consistently provided as planned.
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