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F0677
D

Failure to Provide Adequate Personal and Oral Hygiene Care

Bakersfield, California Survey Completed on 04-24-2025

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 personal and oral hygiene care for two residents who were dependent on staff assistance. One resident was observed with dry, flaky skin on both feet, overgrown and discolored toenails, and blackish debris between the toes. Interviews with nursing staff confirmed the presence of thick, discolored nails and possible fungal infection, as well as dry, red, and swollen toes. Although a CNA reported attempting to clean the resident's feet, the care was not completed due to the resident's pain, and the CNA did not return to finish the task. Facility policy required routine foot care in accordance with professional standards, but this was not followed. Another resident was found to have yellowish, gray teeth, multiple dental caries, and missing teeth, and reported not receiving mouth care on two consecutive days. Review of the resident's ADL documentation showed inconsistent oral care, with gaps in care and documentation. The ADON acknowledged that oral care was not consistently provided and that documentation did not always reflect when care was rendered. Nursing weekly summaries lacked adequate assessment of the resident's oral condition, contrary to facility policy, which required thorough documentation and assessment of oral care.

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