Failure to Provide Required ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for ten residents residing on the secured dementia unit. These residents had varying degrees of cognitive and physical impairment, with many requiring supervision or extensive assistance for eating, bed mobility, transfers, toileting, and personal hygiene. Medical record reviews indicated that several residents had diagnoses such as dementia, Alzheimer's disease, Parkinson's disease, stroke, and other conditions that limited their ability to perform ADLs independently. On specific dates, it was observed and reported by staff that multiple residents were found in the same clothes as the previous day and required incontinence care, indicating that ADL care had not been provided as needed. Staff interviews confirmed that some residents were left in their recliners asleep and unchanged, and that walking rounds to ensure residents were clean and dry were not consistently performed at the start or end of shifts. One CNA reported returning to find residents in the same condition as the previous day, and another CNA and RN corroborated that walking rounds were not routinely completed, resulting in residents needing incontinence care at the beginning of shifts. The facility's policy required that appropriate care and services be provided for residents unable to carry out ADLs independently, in accordance with their care plans. However, documentation and staff interviews revealed that this standard was not met for the affected residents, as they did not receive timely assistance with nutrition, grooming, personal, and oral hygiene. The deficiency was substantiated by direct observations, staff statements, and review of facility records.
Plan Of Correction
Plan of Correction F 0677 This plan of correction is prepared and executed because it is required by the provision of the State and Federal regulations and not because Mennonite Memorial Home agrees with the allegations and citations listed on this statement of deficiencies. Mennonite Memorial Home maintains that the alleged deficiencies do not, individually or collectively, jeopardize the health and safety of the residents, nor are they of such a character as to limit our capacity to render adequate care as prescribed by regulation. This Plan of Correction shall operate as the facility's written credible allegation of compliance as of 6/18/2025. By submitting this Plan of Correction, Mennonite Memorial Home does not admit to the accuracy of the deficiencies. This Plan of Correction is not meant to establish any standard of care, contract, obligation, or position and Mennonite Memorial Home reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; ADL care was immediately provided and documented, including hygiene, toileting, repositioning, oral care, and dressing when original issue was noted on 5/17/25. The Care Plans were reviewed and confirmed current ADL needs. Staff assigned to these residents were reeducated on expectations for complete and timely ADL care on 6/4/2025 and 6/6/2025. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; A full audit of residents with ADL care needs was completed by 6/4/2025. Direct observations, review of documentation, and staff interviews were conducted for all at-risk residents. Any deficiencies identified were promptly addressed with staff follow-up and care plan updates as needed. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur; Staff education was provided to all direct care staff (RNs, LPNs, CNAs) by the Director of Nurses or her designee on 6/6/25. Education focused on the care needs of Residents #10, #11, #12, #13, #14, #15, #16, #20, #21, #22, and other residents requiring assistance, on all ADLs including hygiene, toileting, repositioning, oral care, and dressing. Staff education also covered timely documentation in Point of Care, recognizing and reporting any unmet care needs or refusals of care. Staffing patterns and assignments were reviewed and adjusted to ensure adequate coverage for dependent residents. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place; The Director of Nursing or her designee will monitor the residents 3x/week for 4 weeks to assure dignity for the resident's grooming needs and that residents are clean and dry. Residents will also be checked to ensure they have received and eaten their meals as they desire. Noncompliance will result in immediate reeducation and progressive discipline if necessary. Audits were initiated on 5/19/2025. Audit results will be reviewed during monthly QAPI meetings for 3 months to ensure ongoing compliance.