Inadequate Staffing Leads to Missed Showers for Residents
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene. Specifically, three residents who were dependent on staff for bathing did not receive their scheduled showers. The facility's policy stated that residents would receive assistance as needed to complete ADLs, but this was not adhered to, as evidenced by the shower logs and resident interviews. Resident #1, who was cognitively intact and dependent on staff for bathing, reported that the facility did not have enough staff to meet her needs, resulting in missed showers. The shower logs confirmed that Resident #1 received only a fraction of the scheduled showers over a three-month period. Similarly, Resident #2, who had moderate cognitive impairments and required partial assistance with bathing, also did not receive adequate showers, as confirmed by the shower logs and the resident's representative. Resident #3, who required maximal assistance with bathing, experienced similar issues, although there was some improvement in March 2025. Interviews with staff, including CNAs and an LPN, revealed that the facility had been experiencing a shortage of CNAs, which impacted their ability to provide scheduled showers and other personal care. Staff reported working with insufficient numbers, sometimes caring for a large number of residents alone, which delayed or prevented the completion of scheduled showers. Despite these challenges, the Director of Nursing and the Regional Vice President attributed the missed showers to documentation errors, rather than acknowledging the staffing issues reported by the staff.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A cognitively intact resident with multiple medical conditions, including acute kidney failure and adult failure to thrive, was care planned as being at risk for self-care deficits and scheduled for twice-weekly showers on the night shift. Over a 30‑day period, documentation showed the resident received only two showers or bed baths, with no refusals recorded, despite her stated preference for at least twice-weekly bathing with hair washing. On multiple observations, her hair appeared greasy and unwashed, and she confirmed in interviews that she had not received showers or hair washing as preferred. The DON verified that residents should receive showers and hair care per their scheduled preferences and that staff must document this care, and facility policy required provision of ADL assistance to maintain grooming and personal hygiene.
The facility failed to provide timely meal assistance and scheduled showers to dependent residents. Several residents with dementia and other chronic conditions, who required staff help with eating, were seated in the dining room with uncovered trays placed in front of them and waited a prolonged period before CNAs began feeding them; staff did not offer to reheat cold food or provide alternatives when residents refused to eat. CNAs reported that only two staff assisted about a dozen residents in the dining room and that dependent residents routinely waited until all meals were served before receiving help, contrary to facility policy requiring prompt service and adequate staffing. In addition, a resident with dementia, mobility issues, and a history of stroke had a care plan for scheduled showers twice weekly, but documentation showed only one shower per week with no recorded refusals or evidence that the second scheduled shower was offered, and the administrator could not locate additional shower records.
Two residents who were dependent on staff for ADLs did not receive appropriate nail care. One cognitively intact resident with multiple chronic conditions had long, jagged toenails and reported that staff did not provide toenail care, while a CNA confirmed the condition and was unsure if CNAs were allowed to trim toenails, despite facility documents assigning personal care duties to CNAs. Another resident with anoxic brain damage, severe cognitive impairment, and bilateral hand contractures had long, dirty fingernails with no documentation of nail care, and staff interviews revealed confusion over whether nail care was the responsibility of CNAs, hospice, or an outside service.
The facility failed to provide and document scheduled showers for two dependent residents who required staff assistance with all ADLs, including bathing and hygiene. One resident, cognitively intact with hemiplegia and mental health diagnoses, was care planned for twice-weekly showers but reported only receiving about one per week, with records showing minimal or no documented showers since admission. Another resident with Alzheimer’s disease, malnutrition, and CKD was totally dependent for bathing and scheduled for twice-weekly showers, yet multiple scheduled shower days lacked documentation of care or refusals, and nurse notes did not show any refusals or reattempts. A family member questioned how this nonverbal resident could refuse showers, and the DON confirmed that showers were expected to be provided as care planned unless refusals were documented.
A resident with dementia, COPD, and bilateral upper arm amputations, who was cognitively intact and had orders for bilateral prosthetic devices and OT recommendations for stand-by assist and a scoop plate, was observed eating meals by bending over the plate and scooping food into the mouth rather than using utensils. On multiple observed breakfasts, the resident either pushed away loosely strapped utensils on the prostheses or stopped using a spoon and continued eating with the mouth, while staff either provided only brief verbal encouragement or did not intervene to assist or promote utensil use. Staff later reported that the resident preferred not to use utensils and needed daily encouragement, and the therapy director clarified that specific utensils were intended for use without prostheses, while the resident could use thin-handled utensils with the grabber hooks, indicating a failure to consistently assist with eating as outlined in the facility’s routine care policy.
A dependent hospice resident with Alzheimer’s disease, severe cognitive impairment, underweight status, and documented need for full assistance with eating did not receive required mealtime support. At breakfast, a CNA set up the tray, cut the food, and opened milk but left the room and did not return to feed the resident, who made no attempts to eat and only intermittently tried to drink from the milk carton; the tray was later removed with the food untouched. At lunch, the CNA provided limited hand-feeding, after which the resident consumed only a small amount of ice cream and a bite of beans, and no alternative food choices were offered despite the resident’s dependence on staff for eating, as confirmed by staff interviews and the care plan.
Failure to Provide Scheduled Bathing and Hair Care for Dependent Resident
Penalty
Summary
The facility failed to provide timely bathing and hair washing assistance to a dependent resident in accordance with her care plan, stated preferences, and facility policy. The resident was admitted with diagnoses including acute kidney failure, adult failure to thrive, and depression, and an MDS assessment documented that she was cognitively intact. Her care plan identified a risk for self-care deficit with bathing, dressing, and feeding, with interventions to encourage participation in planning day-to-day care, evaluate her ability to perform self-care, minimize environmental stimuli, and provide ADL assistance as needed. The shower task list scheduled her to receive showers on the night shift on Sundays and Thursdays. However, review of shower documentation over a 30‑day period showed she received only two showers or bed baths, on 03/06/26 and 03/22/26, with no additional showers documented and no refusals recorded. During observations on two separate days, the resident’s hair appeared greasy and unwashed. In interviews conducted immediately following these observations, the resident stated she preferred to have a shower or bed bath at least twice a week with hair washing on those days, and she reported that she had not had her hair washed in weeks and was not receiving bathing at the frequency she preferred. A subsequent observation again showed her hair to be greasy and unwashed, and she confirmed she still had not received a shower or hair washing. The DON confirmed that residents were to receive showers and hair washing per their scheduled preferences and that staff were required to document this care in the medical record, and also confirmed that this resident had documentation of only two showers or bed baths in the 30‑day review period with no documented refusals. Facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene, which was not met in this case.
Failure to Provide Timely Meal Assistance and Scheduled Showers
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with meals to dependent residents and to provide showers according to the established schedule. One resident with dementia, difficulty walking, chronic kidney disease, anxiety, and on hospice required substantial/maximal assistance for eating and was dependent for all other ADLs. Over the prior month, this resident’s meal intake declined from 26–50% to 0–25%, and then to not eating. On the observed morning, the resident was seated in the dining room at 8:53 A.M., breakfast trays arrived at 9:15 A.M., and her uncovered tray was placed in front of her at 9:32 A.M., but staff did not sit to assist her until 9:58 A.M. The CNA then offered food and drink, and the resident consumed about 10–20% of the meal; the CNA did not offer to reheat the food. Another resident with cerebral atherosclerosis, peripheral arterial disease with intermittent claudication, and adult failure to thrive had impaired cognition, required setup or clean-up assistance with eating, and was dependent for all other ADLs. The care plan for weight loss or malnutrition included encouragement to eat, recording meal intake, and providing supplements. On the observed morning, this resident’s uncovered breakfast tray was placed in front of him at 9:35 A.M., and the CNA did not begin assisting until 9:53 A.M. The resident took one bite and then did not want to eat more, and the CNA did not offer to warm the food or provide an alternative. A third resident with hypertension, diabetes, and Alzheimer’s disease had impaired cognition, was dependent for eating and all ADLs, and had a care plan requiring setup, cueing, reminders, and assistance with feeding. This resident’s uncovered meal was placed in front of her at 9:35 A.M., and the CNA did not assist until 9:53 A.M.; the CNA did not offer to warm the food. The resident ate toast with encouragement but refused further eggs after the first bite. Staff interviews confirmed that residents needing assistance with eating are brought to the dining room and must wait until aides finish serving meals on the unit, resulting in no set breakfast time other than around 9:30 A.M. and delays until about 10:00 A.M. before staff can sit to assist dependent residents. CNAs reported that only two staff are typically in the dining room to assist 13 residents at all meals, causing residents to wait and food to become cold. The facility’s Dining Room Service policy stated that meals will be served promptly to maintain adequate temperature and appearance and that adequate staff should be available to assist individuals who need help. Additionally, another resident with dementia, gait and mobility abnormalities, acute kidney failure, history of stroke, and cognitive communication deficit had a care plan indicating assistance with ADLs and a shower schedule on day shift Monday, Thursday, and as necessary. Review of shower documentation over several weeks showed only one shower per week on Thursdays, with no documentation of a second scheduled shower being offered or provided and no refusals recorded for the missed showers, despite the administrator confirming that all showers should be documented in the point-of-care records and being unable to locate additional documentation that showers were offered or provided per schedule.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents who were dependent on staff for activities of daily living. One resident, admitted with multiple diagnoses including COPD, dysphagia following cerebral infarction, malnutrition, hypertension, anxiety, and depression, was cognitively intact and dependent on staff for putting on and taking off footwear. Observation showed this resident had long, jagged toenails, and the resident reported that staff did not provide toenail care. A CNA confirmed the poor condition of the toenails and expressed uncertainty about whether CNAs were permitted to trim toenails. The resident had previously declined podiatry care, and facility documents indicated that CNAs were responsible for personal care and that routine daily care was to be provided. The second resident had an admission diagnosis that included anoxic brain damage, COPD, dysphagia, bilateral hand contractures, ADHD, moderate protein-calorie malnutrition, psychoactive substance abuse, anxiety disorder, and cognitive communication deficit, with severely impaired cognition and dependence on staff for personal hygiene and bathing. The care plan identified self-care deficits related to anoxic brain injury and contractures, and noted the resident was dependent for personal hygiene. There was no documentation in the medical record indicating when this resident’s nails were cleaned or cut. Observations on multiple occasions revealed long fingernails on both hands, with a dark brown substance underneath, and the resident declined to open his contracted hand or accept assistance. Staff interviews showed confusion about responsibility for nail care, with a CNA and an RN suggesting an outside service or hospice might be responsible, while the DON stated that CNAs were responsible for nail care.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers and document bathing care for dependent residents as outlined in their care plans and facility policy. One resident with hemiplegia, tremors, anxiety disorder, and major depressive disorder was care planned and scheduled to receive showers on Mondays and Fridays and required assistance with all ADLs. Review of the shower schedule and shower sheets showed only a few showers documented over a multi-month period, and CNA Point of Care records showed no evidence of showers since admission. The resident reported she did not receive showers as scheduled, stating she was fortunate to receive one shower per week and that she was upset about not getting the two weekly showers planned. Another resident with Alzheimer’s disease, protein calorie malnutrition, major depressive disorder, and chronic kidney disease was care planned as totally or nearly dependent on staff for bathing, hygiene, and dressing, with showers scheduled twice weekly. Review of shower documentation revealed multiple missed shower dates with no evidence that showers were provided on those days. Nursing progress notes contained no documentation of shower refusals or attempts to provide showers at a later time. The resident’s daughter reported staff told her the resident refused showers, but she stated the resident does not speak and expressed confusion about how the resident could refuse. The DON confirmed the missing shower documentation for both residents and stated that showers are to be provided as care planned, requested, and as needed unless refusals are documented, as required by the facility’s ADL policy.
Failure to Provide Appropriate Self-Feeding Assistance for Resident With Prosthetic Arms
Penalty
Summary
The facility failed to provide appropriate assistance and accommodation for self-feeding to a resident with bilateral upper arm amputations who used prosthetic arms. The resident, admitted with diagnoses including dementia, traumatic amputation at both elbows, and COPD, was cognitively intact with a BIMS score of 14 and required staff setup assistance for eating per the MDS. Physician orders directed that bilateral upper arm prosthetic devices be applied before breakfast and removed after dinner, with skin checks each shift. OT notes from 12/03/25 to 02/06/26 documented discharge recommendations for self-feeding that included stand-by assist from staff and use of a scoop plate. During breakfast observations on two separate days, the resident was seen eating without appropriate use of utensils or assistive devices, despite the documented needs and therapy recommendations. On one morning, the resident sat in the dining room with bilateral prostheses and grabber hooks in place; red and white plastic utensils were loosely strapped to the prostheses. The resident pushed the utensils up out of the way and bent over the plate, scooping French toast into his mouth without using utensils, despite an activities assistant encouraging him to use the utensils. On another morning, the resident initially used a regular spoon to eat cereal but then put the spoon down and bent over the plate to eat scrambled eggs with his mouth, without staff coming to assist or encourage utensil use. The therapy director later clarified that the red and white utensils were intended for use when the prostheses were not on, and that the resident preferred thin-handled utensils that could be held with the grabber hooks. A CNA confirmed that the resident typically did not use utensils, preferred to scoop food with his mouth, and required daily encouragement to use a spoon or fork. The facility’s routine care policy included assisting residents with eating and hydration, but staff actions did not consistently reflect this for the resident.
Failure to Assist Dependent Hospice Resident With Meals and Offer Alternatives
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance with eating to a dependent resident. The resident had diagnoses including Alzheimer’s disease, dementia, moderate protein calorie malnutrition, mixed incontinence, osteoarthritis, and cerebral ischemia, and was admitted to hospice with cerebral atherosclerosis. The nursing and nutritional plans of care, MDS, and functional abilities assessment all documented that the resident had severe cognitive impairment, was rarely/never understood, was dependent on staff for all ADLs including eating, received a mechanically altered therapeutic diet, and was on physician-ordered supplements and a weight gain regimen due to being underweight with a BMI of 11.8. Care plan interventions included assisting with feeding, providing and serving supplements and diet as ordered, and monitoring and recording intake at every meal. On the morning of the observed deficiency, a CNA delivered the resident’s breakfast tray, elevated the head of the bed, uncovered the plate and hot cereal, cut up the food, added sugar to the cereal, placed a spoon in the bowl, opened the milk carton, and then left the room. Over the next several minutes, the resident was observed looking toward the television, then with eyes closed, and made no attempts to feed herself. The food remained uncovered and untouched. The resident later attempted only to drink from the milk carton, with no attempts to eat the food. During this time, the CNA was observed seated at a computer in the lounge and did not return to assist with feeding until nearly an hour later, at which point the CNA removed the tray with the food still untouched. The CNA confirmed in interview that the resident had not eaten any of the breakfast meal and that no assistance with breakfast had been provided. At lunchtime the same day, the CNA again delivered the meal tray, repositioned the resident in bed, uncovered and set up the meal, and this time sat next to the resident and provided spoon-fed bites, instructing the resident to take a bite of each item before refusing the meal. The CNA later reported to an RN that the resident consumed only half a portion of ice cream and a bite of beans, and then removed the tray, leaving the remaining ice cream on the overbed table. No alternative food choices were offered after the resident’s limited intake at lunch. In interviews, both the CNA and the RN verified that the resident was dependent on staff for eating, had not been assisted with breakfast, and had not been offered alternative food choices when refusing most of the lunch meal. The deficiency was cited as continued non-compliance from prior surveys.
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