Failure to Provide Necessary Assistance with Activities of Daily Living
Penalty
Summary
Surveyors identified that the facility failed to provide necessary care and assistance with activities of daily living (ADLs) for residents unable to perform these tasks independently. Multiple residents were observed over several weeks with poor personal hygiene, including unwashed hair, long and dirty fingernails, and unshaven faces. Documentation and staff interviews confirmed that showers and incontinence care were not consistently provided or recorded, and that some residents went extended periods without basic hygiene care. In several cases, staff cited insufficient staffing as a reason for missed care. One resident with severe cognitive impairment and incontinence was repeatedly observed with soiled clothing and linens, emitting a strong odor of urine, and with long, dirty fingernails. Staff could not recall when this resident last received incontinence care, and documentation was lacking. Another resident, cognitively intact but dependent on staff for bathing, reported not having a shower for three weeks, with no documentation of showers for the prior 30 days. Staff confirmed that showers were missed due to lack of available personnel. Additional residents dependent on staff for all ADLs were found with greasy, unwashed hair, soiled clothing, and long, uncut nails. Visitors and staff interviews corroborated that showers and hair care had not been provided for several weeks. Documentation of care was incomplete or missing, and staff were often unaware of when residents last received hygiene care. The facility's own policies required documentation of showers and interventions for refusals, but these were not consistently followed.