Failure to Provide ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for two residents, resulting in a deficiency. Resident R1, who was admitted on January 13, 2025, had a Minimum Data Set (MDS) assessment indicating a partial-moderate need for assistance with self-care activities such as bathing, dressing, and using the toilet. Despite this, documentation showed that Resident R1 did not receive a shower on January 25, 2025. Similarly, Resident R3, admitted on August 6, 2019, had an MDS assessment indicating a substantial maximal need for assistance with self-care. However, the facility's records revealed that Resident R3 did not receive showers on multiple dates in January 2025, specifically on the 1st, 4th, 8th, 11th, and 18th. The Director of Nursing confirmed the facility's failure to provide the required ADL assistance for these residents.
Plan Of Correction
Resident R1 received a shower on 1/26/2025 and R3 received a shower on 1/29/2025. A whole house audit 14 day look back was completed for shower documentation for all residents. The Director of Nursing or designee will educate all nursing staff on proper documentation and complete documentation of bathing. The Director of Nursing or designee will audit all residents bathing documentation daily at morning meetings for 2 weeks, and weekly for 2 weeks, and monthly for 2 months. Audits will be reviewed at the monthly QAPI for further recommendations.