Failure to Provide Adequate ADL Assistance and Maintain Cleanliness
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for five residents who were dependent on staff for care. Observations and interviews revealed that residents with significant medical conditions, such as Alzheimer's disease, severe malnutrition, quadriplegia, partial paralysis, and morbid obesity, were not consistently receiving necessary hygiene, grooming, and incontinence care. For example, one resident was found in a stained gown that had not been changed since the previous day and reported going all day without incontinence care, resulting in soreness. Another resident reported sitting in feces for extended periods due to delayed call light responses, and both residents and their rooms were observed to have poor cleanliness, including sticky floors and buildup of residue and particles. Multiple residents and their care plans indicated total dependence on staff for ADLs, yet documentation and direct statements from residents described frequent delays or omissions in care, such as infrequent changing, lack of bathing, and insufficient grooming. Grievance forms over several months documented repeated concerns about long call light response times, lack of incontinence care, missed showers, and unclean linens. One resident developed a facility-acquired moisture-associated incontinence wound, with the DON confirming the need for more frequent incontinence checks and acknowledging that the resident had not refused care. Environmental observations further highlighted deficiencies in housekeeping, with dead ants and unclean conditions persisting in resident rooms after pest treatments. The facility's own policies require maintaining a clean, comfortable, and sanitary environment and providing comprehensive ADL support, but these standards were not met as evidenced by the observed and reported conditions.