Failure to Include Toenail Care in Comprehensive Care Plan
Penalty
Summary
Surveyors found that the facility failed to develop a comprehensive, resident-centered care plan that addressed toenail care for a dependent resident. The resident had a history of stroke with hemiplegia and hemiparesis and was documented on a comprehensive MDS assessment as being dependent on staff for activities of daily living. Review of the resident’s ADL care plan, revised 12/15/25, showed that care for her toenails was not included. On 1/21/26 at 9:44 AM, during an observation with the ADON, the resident’s toenails were noted to appear possibly fungal, brittle, thick, and brownish in color. At 9:56 AM the same day, the ADON reviewed the resident’s care plan and confirmed that the condition of her toenails and related care were not addressed, and acknowledged that the care plan should have included care for her toenails. This omission in the care plan for toenail care constituted a failure to ensure the care plan was complete and comprehensive for this resident’s identified needs.
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