Failure to Provide Adequate ADL Assistance to Multiple Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for 11 of 17 residents, as evidenced by multiple observations, document reviews, and interviews. Residents were observed with soiled clothing, untrimmed fingernails with debris, greasy and unbrushed hair, and in some cases, without bed linens. Several residents were found in wet clothing and bed linens, and documentation did not reflect timely toileting or incontinence care. One resident was not provided lunch until prompted by staff, and another was found in a bed not assigned to them, surrounded by pieces of an incontinence brief. Grievance records and Resident Council minutes further documented concerns about lack of assistance with showers, delayed care from nurse aides, and unmet needs for snacks, water, and catheter care. Facility records indicated that some residents had not received showers as frequently as expected, and grievances confirmed delays in care and lack of staff responsiveness. Resident Council minutes from several months highlighted ongoing issues with staff not providing care, not passing snacks or water, long call light response times, and not completing rounds. The Nursing Home Administrator confirmed the failure to provide necessary ADL assistance for the affected residents.