Failure to Provide Required ADL Assistance and Hygiene Care
Penalty
Summary
Multiple residents with significant medical and functional impairments did not receive required staff assistance for activities of daily living (ADLs), including toileting, incontinence care, nail care, hair care, and oral hygiene. In one instance, a newly admitted female resident with a recent hip fracture was left unattended for over five hours, resulting in her lying in bed with heavily soiled linens and incontinence briefs. Staff interviews and assignment board checks revealed that no CNA had been assigned to her, and no bedside care was provided during that period, despite her repeated calls for help. Other residents with diagnoses such as osteomyelitis, intellectual disability, chronic kidney disease, morbid obesity, and dementia were observed with long, unkempt fingernails, visible debris, and poor grooming. Family members and residents reported that oral care, hair brushing, and shaving were not performed daily as required, with some residents stating they had not received grooming or oral care for weeks or only on shower days. Observations confirmed the presence of thick dental plaque, disheveled hair, and facial hair that had not been addressed despite repeated requests from residents. Staff interviews confirmed that ADL care, including incontinence checks and grooming, was not consistently provided according to care plans and facility policy. In several cases, staff acknowledged that residents had not been checked or assisted for extended periods, and that care was only provided after deficiencies were brought to their attention. Facility policies required incontinence checks at least every two hours and daily grooming and oral care, but these procedures were not followed for multiple residents.