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F0677
D

Failure to Provide Grooming Assistance for Dependent Residents

Bryn Mawr, Pennsylvania Survey Completed on 03-06-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary grooming services for two residents who required assistance with activities of daily living. Resident R243, admitted with conditions including chondrocalcinosis, lack of coordination, and severe cognitive impairment, was observed with an inadequately groomed beard. Interviews with the resident and a family member revealed that the facility had not provided grooming assistance since the resident's admission, necessitating family intervention for shaving. A licensed nurse confirmed the absence of documentation or evidence of grooming assistance for this resident. Similarly, Resident R244, who had diagnoses including cirrhosis of the liver, muscle weakness, and intact cognition, was observed with an overgrown beard and hair over the upper lip. The resident reported inadequate grooming since admission, which affected his ability to eat properly. The Director of Nursing confirmed the resident's need for grooming assistance and the overgrown state of his beard. These findings indicate a failure by the facility to maintain adequate grooming for residents requiring assistance.

Plan Of Correction

(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R243 and R244 facial hair were trimmed by licensed staff. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of current residents was conducted by the DON/Designee to ensure that facial hair is groomed based on residents' wishes. Any additional concerns identified during the audit will be corrected immediately. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: DON/Designee will re-educate facility clinical staff on the components of this regulation with an emphasis on ensuring that residents receive appropriate grooming of hair/facial hair and footcare/nail care. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: DON/Designee to conduct random visual audits of 10 residents 1x a week for 4 weeks, 2x a month for 3 months, then monthly for 2 months to ensure that residents are being groomed appropriately and that facial hair is trimmed. The findings of these quality monitoring activities will be reported to the Quality Assurance/Performance Improvement Committee monthly for 6 months.

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