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F0677
E

Failure to Provide Timely ADL Assistance and Personal Hygiene Care

Tyler, Texas Survey Completed on 05-05-2025

Penalty

Fine: $419,660
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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 assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. For one resident with multiple fractures, cognitive deficits, and impaired mobility, observations showed that her call light for assistance remained unanswered for over an hour while she waited for incontinent care. Her care plan indicated she required maximum assistance with bathing and was dependent on staff for all ADLs due to her condition. Another resident, who had diagnoses including muscle weakness and cognitive communication deficit, also experienced significant delays in receiving incontinent care. Observations revealed that her call light was on for over an hour, with multiple staff members entering and exiting the room without providing the needed care. The resident and her family confirmed that staff were slow to respond to call lights. The facility's policy required all staff to respond promptly to call lights, but this was not followed, as confirmed by the DON, who stated that waiting over an hour for care was unacceptable. A third resident, with dementia and anxiety disorder, was found to have received only one shower during the entire month, according to the facility's shower log. Although staff believed this was a documentation issue, they could not provide evidence that more showers were given. The facility's policy required regular bathing services, but documentation did not support that this standard was met for the resident.

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