Failure to Follow Aspiration Precautions and Provide Timely Incontinence Care
Summary
The deficiency involves the facility’s failure to follow physician orders and speech therapy recommendations for safe feeding positioning, and failure to follow its own incontinence care policy requiring checks at least every two hours or as needed. One resident with documented oropharyngeal dysphagia and aspiration precautions was repeatedly observed receiving meals while not positioned upright at 90 degrees as ordered. This resident was seen in a reclining chair at approximately 30 degrees while being fed lunch and coughing after each bite, and later in bed with the head elevated only about 30 degrees while breakfast was placed in front of them. When the resident requested that the head of the bed be raised, a CNA stated the resident could do it independently and left the room. The DON later stated the resident was alert and oriented and “keeps scooting self-down in bed,” but when the room was entered, the resident had eaten only two bites of breakfast and was not positioned as ordered. During the survey, the resident was not observed sliding down in bed or chair. Clinical records for this resident included a modified barium swallow study documenting at least moderate oropharyngeal dysphagia with reduced bolus control, delayed swallow initiation, and suspected reduced swallow safety with possible aspiration, along with recommendations for a puree diet, teaspoon sips of thin liquids, slow 1:1 supportive feeding assistance, and strict adherence to swallow precautions in an upright/midline 90-degree position. The physician order sheet documented puree solids and nectar thick liquids, upright positioning for all oral intake, slow rate, small bites/sips, alternating solids and liquids, no straws, and aspiration precautions. A speech therapy discharge summary reiterated the need for upright posture during meals and for more than 30 minutes after meals, with prognosis dependent on staff follow-through. Despite these orders and recommendations, staff and nursing leadership relied on the assertion that the resident could reposition independently and did not ensure the ordered upright positioning during meals. The facility also failed to provide incontinence care at least every two hours or as needed, as required by its incontinence care policy. One resident was observed with a large bulging brief; upon assessment by a nurse, the resident was found wearing a brief with a urine-soaked and saturated insert, and the nurse stated it took over two hours to become that saturated and was unsure when the last incontinence care was provided. Another resident reported being wet and that staff would not change the brief; when a CNA provided care, the resident was found with a saturated panty liner inside a saturated brief, and the CNA stated they provided incontinence care only twice per shift (at the beginning and end). A third resident activated the call light and indicated the need for a brief change; staff turned off the call light, informed another CNA, and incontinence care was not provided until approximately 25 minutes after the initial observation. A fourth resident stated they needed to use the bathroom and had been holding urine while waiting for staff; when checked, the front of the brief appeared dry, but the back was saturated with urine. CNAs reported providing incontinence care at the beginning and end of shifts, while the DON and ADON stated incontinent residents should be checked and changed every 2–3 hours or every two hours and as needed. MDS assessments documented that these residents were always or frequently incontinent and required staff assistance for toileting, and one resident’s care plan called for peri-care after each incontinent episode.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with spinal cord disease, chronic pain, COPD, right-eye blindness, and a history of falls required one-person assist for transfers and ADL. She repeatedly used her call bell and yelled for help after breakfast because she wanted to get up, shower, and attend BINGO, but staff did not assist her out of bed until mid-afternoon. Staff said the assigned NA got behind with showers and other duties, and an RN acknowledged the resident had voiced concern that no one had helped her up when she requested it.
A resident who was dependent on staff for toileting and transfers was left in bed in an incontinent brief for an extended period after asking for help, crying that staff told her to pee her pants and that this happened often. Staff later provided incontinent care and used a mechanical lift for transfer. Another resident who needed supervision and assistance with meals sat with food in front of her for 45 minutes before staff helped her eat, while staff reported the dining room was short-staffed and the resident needed more meal assistance.
A resident with severe cognitive impairment, Alzheimer’s disease, and dependence on staff for oral hygiene did not receive routine tooth brushing during morning ADL care. Nursing assistants helped with bathing, dressing, perineal care, grooming, and transfer, but oral care was not offered or completed. A family member said staff did not routinely brush the resident’s teeth, and the RN stated oral care and brushing were expected with morning and evening cares per facility policy.
Failure to provide routine grooming: a resident who was dependent on staff for ADLs and preferred no facial hair was observed with visible facial hair on multiple occasions, and records for baths/showers did not show shaving was offered, completed, or refused. The resident stated staff did not ask about shaving, and RN and DON interviews confirmed shaving should be offered as part of grooming and documented if refused.
Failure to provide timely nail care for three residents was identified during observation, interview, and record review. Two residents with significant functional dependence had fingernails that were about 1/2 inch long, thick, and yellow, and one resident with DM and limited ability to bend had toenails about 1/2 inch long. Staff interviews showed that overgrown nails should be reported and that nail trimming was part of resident care, while the DON stated there was no reason the nails had not been cut.
Two residents who depended on staff for personal hygiene were left with unwanted facial hair despite facility policy stating grooming includes shaving and removal of facial hair. Staff confirmed CNAs were responsible for addressing facial hair during shower time, and both residents were observed with chin hairs; one resident with severe cognitive impairment said she wanted them shaved, and the other said the hair bothered her and made her feel like an odd ball.
Failure to Assist Resident With Requested Transfer and Morning Care
Penalty
Summary
The facility failed to assist a resident who required staff help with transfers out of bed when she requested it. Resident #8 was admitted with diagnoses including disease of the spinal cord, chronic pain, COPD with difficulty breathing, left hand contracture, and a history of falling. Her MDS indicated intact cognition, impairment on one side of the upper extremity, and the need for partial/moderate assistance with bed mobility and chair transfers, as well as substantial/maximal assistance with sit-to-stand. Her care plan also identified that she had impaired vision due to blindness in the right eye and required one-person assistance with transfers, with staff directed to assist her with all ADL she could not complete independently. On the day in question, Resident #8 stated she wanted to get up early, at least by 10:00 AM, and was unable to transfer independently. She reported that after breakfast she used her call bell repeatedly and yelled for staff because she wanted to get up, shower, and attend BINGO, but she was not assisted out of bed until about 2:45 PM. She stated that when staff finally came to her room, she was told they were running behind, and she said it hurt her feelings that she had to repeatedly request help. Staff interviews confirmed that Resident #8 was a one-person assist with a stand/pivot transfer and that she usually stayed in bed except for BINGO and showers. NA #1, who was new to the hall and assigned to Resident #8’s area, stated she got behind because she did not know the residents well, had two showers to provide, and was also assigned to assist in the dining room during lunch. Nurse #2 acknowledged that Resident #8 said before lunch that she wanted to go to BINGO and was concerned no one had helped her out of bed, but she did not assist because she was finishing medication pass. The Nurse Supervisor stated BINGO was scheduled for 2:30 PM and that no one had told her Resident #8 had not been assisted out of bed; the DON and Administrator both stated that if Resident #8 asked for assistance, staff should have provided it when requested.
Delayed Toileting Assistance and Meal Supervision
Penalty
Summary
The facility failed to provide timely toileting assistance and transfer support for a resident who was dependent on staff for toileting and transfers, was frequently incontinent of bowel and bladder, and had diagnoses including non-traumatic spinal cord dysfunction, diabetes, and dementia. The resident’s MDS and care assessments identified the need for extensive assistance, including assistance of two for transfers and toileting, use of a full body mechanical lift, peri care after incontinent episodes, and toileting every three hours. During observation, the resident was found lying in bed in an incontinent brief, crying, and stating that staff told her to stay in bed and pee her pants so they could clean her up there. The resident stated this happened all the time and that staff shut off her call light just about every day. The resident remained wet and in bed for an extended period before staff returned to provide care. A nursing assistant later entered, acknowledged the resident was wet, and performed incontinent care, including cleaning feces and urine from the resident’s skin, applying barrier cream, and putting on a clean brief and pants. After care was completed, the nursing assistant had to leave and return with another staff member to complete the transfer using a ceiling lift before the resident was taken to the dining room for lunch. Staff interviews confirmed the resident should not have had to wait when she needed the bathroom and that timely toileting assistance was expected to prevent incontinence and skin breakdown. The facility also failed to provide timely supervision and assistance with eating for another resident who was identified as cognitively intact and independent with eating on the quarterly MDS, but whose nutritional assessment stated the resident normally ate 51-75% of most meals and was assisted with meals for optimal intake. During lunch observation, there was not enough staff in the dining room to assist residents, and at least two residents sat with food in front of them without eating or receiving help. The resident remained seated with a plate of food in front of her for 45 minutes before staff assisted her to eat. Staff interviews indicated the resident had begun to need more help with meals, had started pocketing food, and required supervision and cueing while eating. The DON stated residents who required supervision with eating should be watched closely and assisted in a timely fashion when they stopped eating or had not started eating.
Failure to Provide Routine Oral Care
Penalty
Summary
The facility failed to provide assistance with routine grooming cares, including oral care, for a resident who was dependent on staff for oral hygiene, personal hygiene, eating, and dressing. The resident had severe cognitive impairment with diagnoses including Alzheimer’s disease, anxiety, and depression. The care plan identified a self-care performance deficit related to Alzheimer’s disease and dementia, along with impaired balance and weakness, and specified that the resident required total assistance of one with oral care and had her own teeth in good condition. A family member stated staff did not routinely brush the resident’s teeth and believed flossing occurred only occasionally. During morning observation, nursing assistants assisted the resident with transfer, bathing, dressing, perineal care, grooming, and getting her ready for the day, but oral care was not offered or completed. One nursing assistant later verified he did not offer to complete oral care or brush the resident’s teeth and stated he was not used to morning cares after recently working evening shifts. Another nursing assistant stated his usual practice was to complete oral care in the evening. The RN stated oral care and brushing of teeth were expected with morning and evening cares, and the facility policy required residents with their own teeth to have them brushed every morning, every evening, and as needed.
Failure to Provide and Document Routine Shaving for a Dependent Resident
Penalty
Summary
The facility failed to ensure routine personal hygiene, specifically shaving, was completed for a resident who was dependent on staff for ADLs. The resident’s quarterly MDS dated 5/11/26 indicated intact cognition, no hallucinations, delusions, behaviors, or rejection of care, and dependence on staff for personal hygiene, toileting, showering, dressing, and mobility. The care plan identified a preference for no facial hair and directed staff to provide grooming on shower days and as needed, with the resident totally dependent on staff for personal hygiene and oral care. Review of progress notes from 5/1/26 through 6/3/26 showed no documentation of refusals or completion of shaving. Weekly skin/bath assessments on 5/22/26 and 5/29/26 documented bed baths, and the weekly bath audit on 5/27/26 documented a shower, but none of these records showed that facial shaving was offered or completed. During observation and interview, the resident was seen with approximately 1/4 inch facial hair and stated staff did not ask if she wanted to be shaved and that she found it embarrassing to have to ask. On a later observation, the resident still had facial hair and stated no staff had asked if she wanted it removed. RN-A and RN-D stated shaving should be offered when staff notice facial hair and that shaving is part of daily grooming, while the DON stated shaving should be offered with showers and as needed and documented if refused.
Failure to Provide Timely Nail Care for Three Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal care, specifically nail care, for three residents reviewed for ADL care. Resident #88 had a history of CVA, lack of coordination, muscle weakness, muscle spasm, anemia, and hand contractures, and was fully dependent for self-care. On observation, he was in bed with contracted hands and fingernails about 1/2 inch long on both hands that were thick and yellow; he nodded yes when asked if he wanted his nails trimmed. Resident #45 had Parkinsonism, other lack of coordination, weakness, localized edema, chronic pain, wrist drop, and muscle weakness, with severely impaired cognition and full dependence for self-care. On observation, he was in bed with tremors in both hands, and all fingernails on both hands were about 1/2 inch long and thick and yellow. He stated he wanted his nails trimmed and did not remember whether he had been offered nail trimming or when they were last trimmed. Resident #67 had acute respiratory failure with hypoxia, CHF, type 2 diabetes mellitus, muscle weakness, muscle wasting, and lack of coordination. Although his MDS reflected intact cognition and independence with personal hygiene, he stated he could trim his fingernails but could not bend down to trim his toenails. Observation showed toenails about 1/2 inch long on both feet, and he stated that he had neither requested nor been offered toenail trimming. Interviews with CNA staff and the nurse in charge showed awareness that nail care was part of resident care, that overgrown nails should be reported, and that nail trimming was important, while the DON stated there was no reason the residents' nails had not been cut.
Failure to Provide Grooming and Facial Hair Removal
Penalty
Summary
The facility failed to provide necessary ADL services for two sampled residents who were dependent on staff assistance for personal hygiene and grooming. Facility policy stated that grooming includes shaving and removal of facial hair, and staff interviews confirmed that CNAs were responsible for shaving residents as needed during shower time. Surveyors observed Resident #67 with several long, curly facial hairs on her chin during one observation, and the hairs were still present during a later observation and interview. Resident #67, who had diagnoses including weakness and vascular dementia and a BIMS score of 4 indicating severe cognitive impairment, stated she did not know the hairs were there and said she would like someone to shave them off. Resident #59 was also observed with scattered chin hairs approximately one-half to three-fourths of an inch long. She stated she could not recall staff asking whether she wanted them shaved, said it would be good if staff had a time and place to get it done, and explained that the facial hair bothered her and made her feel like an odd ball. She said she wanted the hair shaved, not plucked. CNA #1, LPN #2, and the ADON all confirmed that facial hair removal should be addressed during shower time and that leaving female residents with unwanted facial hair was a dignity issue. Resident #59 had diagnoses including unspecified dementia, weakness, and hypertensive heart and chronic kidney disease without heart failure, and her BIMS score was 08 with MDS documentation showing substantial/maximal assistance needed for personal hygiene.
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