Failure to Provide Necessary ADL Care and Assistance
Penalty
Summary
Surveyors identified multiple failures by facility staff to provide necessary assistance with activities of daily living (ADLs) for several residents. One resident with Alzheimer's disease and chorea, who required substantial to maximum assistance for bathing and hygiene, was observed unshaven at breakfast. Staff interviews revealed that shaving was typically performed on shower days, but due to staffing shortages and the bath aide being reassigned to other duties, residents were not consistently receiving showers or being shaven as scheduled. Documentation showed missed or infrequent bathing opportunities, and staff confirmed the resident had not refused care. Another resident with severe cognitive impairment and dependent on staff for dressing was repeatedly observed in soiled clothing throughout the day, including at meals and while resting in bed. Despite multiple staff members interacting with the resident, her soiled clothing was not changed. Staff interviews confirmed the resident was fully dependent for dressing and that her clothing should have been changed if dirty, but this was not done. A third resident with a history of cerebral infarction and cognitive decline required substantial assistance with bathing and personal hygiene. This resident was observed unshaven with greasy, dirty hair, and records indicated missed or unattempted showers. Staff confirmed the resident had not refused care and that personal hygiene was not consistently provided. Additionally, another resident with moderate cognitive impairment and a history of stroke, who required substantial to maximum assistance with eating, was observed at meals without receiving needed feeding assistance until staff intervened later. Staff acknowledged the resident's increased need for help with eating, but assistance was not provided in a timely manner.