F0677

E

Failure to Provide ADL Assistance, Grooming, Incontinence Care, and Ordered 1:1 Feeding

Homewood, Illinois Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), grooming, incontinence care, and ordered feeding assistance to multiple dependent residents, despite documented care plans and policies. Several residents with documented ADL self-care deficits and cognitive or physical impairments were observed with unaddressed hygiene and grooming needs. One resident with hemiplegia and severe cognitive impairment was seen with large clumps of food on his chest after breakfast; the LPN acknowledged the spilled food but did not remove it or change the soiled shirt. Another resident with lumbar myelopathy, who required assistance with dressing and personal hygiene and was cognitively intact, was observed wearing a shirt covered in white debris, with a long beard and mustache and long, broken fingernails; the resident stated he needed help with shaving and that nobody cut his nails. A third cognitively intact resident who required assistance with personal hygiene had long, broken fingernails and reported he could not cut them himself and only picked at them.

The facility also failed to provide timely incontinence care and scheduled showers as care planned and as required by policy. One cognitively intact resident, dependent on staff for toileting, was observed with a saturated incontinence brief; an LPN opened the brief, confirmed the resident was wet, stated she would send someone to change him, then re-taped the wet brief and left the room. Another resident, frequently incontinent of bowel and bladder and requiring assistance with most ADLs, reported sitting in urine for extended periods, especially on night shift, and stated that call lights were not answered and that CNAs made excuses when showers were requested; records showed the resident was scheduled for showers twice weekly but had not received a shower since the prior week, with the last documented shower several days earlier. A second resident, cognitively intact and requiring partial to moderate ADL assistance, reported issues with getting scheduled showers, stating staff did not provide them as planned; documentation showed only two showers since admission, despite twice-weekly scheduling. A further resident, frequently incontinent and requiring substantial to maximal assistance with toileting and hygiene, reported waiting to be changed since after lunch, remaining wet with a bowel movement while staff repeatedly told her to wait and did not return.

Additional failures in grooming and feeding assistance were identified. One resident with facial hair on the chin reported repeatedly asking staff for a razor and a shaving basin so she could remove the hair herself, but the hair remained unaddressed at the time of observation; nursing leadership later told the resident they would shave and clean her up after medications, and the resident reiterated she had been asking for shaving supplies. Another resident with severe cognitive impairment, dysphagia, and significant weight loss risk had an active physician order for 1:1 assistance while eating or drinking. During a lunch observation period, the resident received a lunch tray but no staff member provided continuous one-to-one feeding assistance, prompts, or supervision, while staff assisted other residents in the dining room. A CNA stated this resident did not require 1:1 feeding and ate like everyone else, while the registered dietician and DON both identified the resident as a 1:1 feed and the DON affirmed staff are expected to follow physician orders and care plans. Facility policies and job descriptions required staff to assist with ADLs, keep residents clean and dry after incontinence, ensure dependent residents are dressed in clean clothing, keep nails trimmed, provide scheduled showers, and honor grooming preferences such as shaving facial hair, as well as to provide person-centered care consistent with residents’ rights and baseline care plans; these documented requirements were not followed in the observed instances.

The facility’s own ADL, incontinence care, baseline care plan, and residents’ rights policies emphasized maintaining residents at their maximal level of functioning, providing assistance with ADLs and grooming (including shaving facial hair per preference), scheduling and documenting showers or bed baths, and keeping residents dry, comfortable, and odor free. Despite these written standards, multiple residents who were incontinent, dependent, or partially dependent for ADLs did not receive timely toileting, incontinence care, showers, nail care, grooming, or ordered feeding assistance. Staff interviews, including with CNAs, an LPN, the wound care coordinator, the registered dietician, and the DON, confirmed awareness of residents’ needs and expectations that staff follow care plans and physician orders, yet the observed care did not align with those requirements for the residents cited in the findings.