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F0677
D

Failure to Provide ADL Care and Grooming

Harrisonburg, Virginia Survey Completed on 04-11-2025

Penalty

Fine: $116,624
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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

Facility staff failed to provide adequate activities of daily living (ADL) care, specifically grooming and showering, for one resident who was dependent on staff for these needs. The resident, who had severe cognitive impairment and multiple diagnoses including urinary tract infection, muscle weakness, and underweight status, did not receive a shower or proper grooming on the day in question. Staff statements conflicted regarding whether a shower was provided, with one CNA documenting that a shower was given, while both an LPN and a physical therapist assistant indicated the resident was not showered and remained in bed for much of the morning. The resident's daughter also reported that her father was not groomed and appeared unshowered, with greasy hair. Review of facility documentation showed inconsistencies between staff statements and recorded care, as the CNA had documented both a bed bath and a shower, but other staff and family observations contradicted this. The facility did not have a policy for ADL care, and the incident was confirmed through interviews and record reviews. The lack of consistent and accurate care documentation, as well as the absence of a clear ADL policy, contributed to the failure to provide necessary hygiene and grooming for the resident.

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