Failure to Perform Timely Incontinence Checks and Care Over Night Shift
Summary
The deficiency involves the facility’s failure to provide timely incontinence checks and care for a resident who was dependent on staff for toileting hygiene and had a history of bladder incontinence. The resident’s MDS showed intact cognition (BIMS 14/15), hemiplegia following a CVA affecting one upper and lower extremity, decreased mobility, and frequent bladder incontinence. The care plan identified the need for assistance with ADLs related to stroke-related weakness and balance/gait impairment, and specified that the resident required assistance of one staff member for toileting and that the peri-area should be cleaned with each incontinent episode. Facility policy required rounding on all residents approximately every two hours and at the end of each shift, including incontinence checks and peri-care or toileting as necessary. On the evening and night in question, documentation and interviews showed that the resident was last documented as continent at approximately 3:10 PM after toileting. Around 6:30 PM, a CNA (Staff B) informed another CNA (Staff A) that both residents in the room were ready for bed. At approximately 6:38 PM, the resident used the call light to request assistance, and Staff A assisted him to his recliner per his request; during this interaction, the resident told Staff A to leave the room using profanity. Staff A then assisted the roommate before exiting. Later, at about 9:15 PM, an RN (Staff C) administered medications and asked if the resident was ready for bed; the resident declined. At 10:00 PM and again at 12:00 AM and 2:00 AM, another CNA (Staff D) reported only observing the resident in his recliner during rounds, without physically checking his incontinence brief. The POC entries at 12:33 AM and 2:33 AM showed no void documented at those times. Around 4:00 AM, the call light report showed the resident requested assistance. Staff A stated that at this time the resident requested to go to bed, but Staff A convinced him to remain in the recliner because of the time, and instead provided a urinal. Staff A acknowledged he did not return to empty the urinal or physically check the resident’s brief, relying on the resident to use the call light if he needed changing. Staff A also did not inform the nurse or other aides that the resident had previously told him to leave the room. At approximately 6:20 AM, the POC showed the resident was incontinent, and between about 6:30 and 6:45 AM, two CNAs (Staff F and Staff G) assisted the resident up for the day and found his clothes, incontinence pad (chuck), and recliner soaked with urine, and noted he was still wearing the previous day’s clothes. Staff F reported that the resident was wearing a pull-up brief, which he could not manage independently due to hemiplegia, and that the recliner was saturated from top to bottom. Staff F and Staff G both reported a strong urine odor and confirmed that no one else had come in to toilet or change the resident during the night, and that staff had not been physically checking his brief, instead relying on visual checks and the resident’s call light use. The DON stated that the resident being upset was not a reason to avoid attempting physical check and changes, and that the CNA should have reported the resident’s refusal of care so that others could intervene.
Penalty
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A resident with severe cognitive impairment, an indwelling catheter, and a need for assistance with dressing and personal hygiene was observed wearing the same soiled hospital gown and socks from the prior evening, with disheveled grooming and a strong urine odor in the room. A NA changed the catheter bag but did not offer a clean gown or morning cares, despite the care plan directing staff to provide peri-care and offer clothing assistance. The RN manager stated staff should have offered a clean gown and cares, and the DON stated staff were expected to offer cares and document refusals.
Failure to assist a resident with oral hygiene. A cognitively intact resident admitted with a fracture required ADL assistance, including oral hygiene, per MDS and care plan. The resident stated staff did not provide a toothbrush or offer help brushing teeth, and the toothbrush was later found still in its original wrapper by the sink. The assigned CNA confirmed oral care was not provided, and the DNS stated residents should be offered oral care twice daily.
Failure to provide ADL care and hygiene assistance: One resident with Parkinson’s disease, DM2, dysphagia, and polyneuropathy was scheduled for showers twice weekly but had no documented bath or shower for nearly two weeks and was observed with dirty clothing, skin flakes, messy hair, and facial stubble. Another resident with parkinsonism and Alzheimer’s disease, who required maximal assistance with personal hygiene, was repeatedly observed with dirty fingernails. Staff stated nails should be cleaned when dirty and checked daily, but the resident’s nails remained unclean.
Failure to Provide Scheduled Bathing Assistance: Three residents who required help with ADLs did not receive bathing as scheduled. One resident had COPD, DM, and CHF and needed help with personal hygiene; another had a functional deficit and needed partial bathing assistance; all had bath schedules for 3 times weekly, but shower sheets showed missed or inconsistent baths. The DON stated showers should occur 3 times weekly and that refusals should be documented with a bed bath offered, while CNA and RN interviews indicated showers were sometimes missed and shower sheets were not always completed.
Failure to Provide Nail Care During ADL Assistance: Multiple residents who required help with grooming and hygiene were observed with long, dirty, uneven fingernails and black/brown debris under the nails. Several residents stated they wanted their nails cleaned and clipped, and one resident with stroke-related R-sided weakness and hand contractures had overgrown nails, including nails digging into the palm. The DON stated nail care is part of grooming care, and one resident with multiple comorbidities and substantial/maximal assistance needs reported that no one offers to clean or cut his nails.
The facility failed to keep call lights within reach for multiple residents and failed to provide needed grooming assistance for a resident who required help with ADLs. Residents were observed in bed or in a wheelchair without accessible call lights, and one resident with dementia and neurocognitive disorder with lewy bodies had long facial hair despite needing staff assistance for shaving. Staff interviews confirmed the call lights were not properly accessible and that the resident needed help with personal hygiene.
Failure to Provide ADL Assistance and Morning Grooming
Penalty
Summary
The facility failed to provide assistance with dressing and personal hygiene, including offering a clean gown and morning grooming, for one resident who was unable to perform activities of daily living independently. The resident had severe cognitive impairment, was rarely or never understood, and had diagnoses including ichthyosis vulgaris, major depressive disorder, mixed obsessional thoughts and acts, bipolar disorder, candidiasis of the skin and nails, and anxiety. The resident was always continent of bowel, used an indwelling catheter, and required partial to moderate assistance with personal hygiene, upper and lower dressing, and footwear. The care plan directed staff to provide peri-care every morning, at bedtime, and as needed, and to offer assistance with clothing; the resident often preferred to wear a hospital gown. During observation, the resident was seen lying in bed wearing the same soiled hospital gown and red gripper socks that had been observed the previous evening. The resident was unshaven, had disheveled hair, and the room smelled strongly of urine. The catheter leg straps remained attached to the resident's left leg while the catheter drainage bag was lying on the floor beside the bed. A nursing assistant entered the room, asked if the resident wanted to put on clothes, and the resident responded "nightgown." The nursing assistant changed the catheter bed bag to a leg bag but did not offer to change the gown or provide morning cares. The nursing assistant later stated the resident had already received morning cares and did not know why the leg bag had not been connected earlier. The RN manager stated staff should have offered a clean gown and cares when the catheter leg bag was connected, and the DON stated staff were expected to offer cares and continue to offer and document if refused.
Failure to Assist Resident With Oral Hygiene
Penalty
Summary
The facility failed to ensure a resident was assisted with oral hygiene for 1 of 2 sampled residents reviewed for ADLs. Resident 81 was admitted in 6/2026 with a diagnosis of a fracture, and the 6/29/26 admission MDS indicated the resident was cognitively intact and required assistance with ADLs including oral hygiene. The 6/25/26 care plan stated the resident required the assistance of one person for personal hygiene and mobility. During interview on 7/6/26, Resident 81 stated that since admission staff had not provided a toothbrush for oral care or offered assistance with oral hygiene. On 7/7/26, the resident’s toothbrush was observed still in its original plastic wrapper in a basin by the sink, and the resident stated that although a bed bath had been provided, no one had offered to help brush teeth. Staff 8, the assigned CNA for day shift, stated the toothbrush was by the sink but she did not assist the resident with oral care during the morning shift. Staff 2, the DNS, stated residents were to be offered oral care at least two times a day, in the morning and in the evening.
Failure to Provide ADL Care and Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary care and services for activities of daily living for two residents. One resident had diagnoses including left femur fracture/displacement, Parkinson’s disease, diabetes mellitus type II, dysphagia, and polyneuropathy, and his care plan and CAA directed staff to provide substantial to moderate assistance with eating, showering, and shower room transfers. Although shower days were scheduled for Tuesday morning and Friday evening, the shower book contained no completed shower sheets for him, and the EHR had no documented evidence that he received a bath or shower between 06/19/2026 and 07/03/2026. During observation, he was seen wearing dirty clothing and socks, with skin flakes on his sweatshirt, messy hair, and stubble on his face. He stated he had not received a shower for almost two weeks and said he likes to be clean-shaven. Another resident had diagnoses of parkinsonism and Alzheimer’s disease, with severely impaired cognition documented on MDS assessments and care planned for maximal assistance with personal hygiene. On multiple observations, her fingernails had a brown substance under them while she sat in her wheelchair in common areas and the dining room. Staff interviews stated that dirty or unclipped nails should be cleaned when seen, especially on shower day, and that nails should be checked every morning, but the resident’s nails remained dirty during the observations. The facility did not provide a policy for activities of daily living for a dependent resident.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
Provide care and assistance with activities of daily living was not ensured for 3 sampled residents who required bathing assistance. Resident #3 had a care plan dated 05/18/26 identifying a functional deficit related to COPD, diabetes mellitus, and CHF, and requiring assistance with personal hygiene. An undated bath list showed the resident was to receive baths on Monday, Wednesday, and Friday, but shower sheets documented baths only on 06/03/26 and 06/17/26. Resident #4 also had an undated bath list showing baths scheduled for Monday, Wednesday, and Friday, but shower sheets documented baths only on 06/01/26, 06/10/26, and 06/19/26. Resident #6 had a care plan dated 06/16/26 identifying a functional deficit related to osteoarthritis and requiring partial assistance with bathing. An undated bath list showed baths scheduled for Monday, Wednesday, and Friday, but shower sheets documented baths only on 06/03/26, 06/10/26, 06/19/26, 06/22/26, 06/24/26, and 06/29/26. The DON stated residents should receive showers three times weekly, that some residents were scheduled for two days weekly if care planned and scheduled, and that if a shower was refused the nurse was expected to offer a bed bath and document the refusal. CNA #1 stated showers were sometimes missed or refused and that they usually did not turn in a shower sheet. RN #3 stated shower sheets were completed by CNAs and reviewed by the charge nurse, and that if a resident refused a shower the nurse would follow up, but they did not know why the shower sheets were not completed for the three residents and stated it appeared the showers had not been given.
Failure to Provide Nail Care During ADL Assistance
Penalty
Summary
The facility failed to provide nail care for residents who required assistance with ADLs, affecting 5 of 5 residents reviewed for nail care in a sample of 37. The active MDS for the residents showed they required assistance with grooming and hygiene. On observation, R10 was resting in bed with long uneven fingernails and black/brown substances under the nails, and stated she wanted her nails clipped and cleaned. R32 was observed with long dirty fingernails and black/brown substances under the nails and said she wanted staff to clean, file, or slightly clip her nails and was okay with staff cleaning them. R33 was resting in bed with long dirty fingernails and black/brown substances under the nails and stated she would love to have her nails clipped and cleaned. R34, who had right-sided weakness from a stroke and contracture of the right hand and wrist, was observed with long, jagged, uneven fingernails and brown discoloration on the nail beds. She stated she needed her fingernails clipped, especially on the right hand, and showed an overgrown right index fingernail curved at the tip and the 3rd and 4th fingernails digging into the palm of her right hand. R21's care plan showed an ADL self-care performance deficit related to multiple diagnoses, including limited mobility, history of pressure ulcer, type 2 diabetes mellitus with diabetic polyneuropathy, chronic kidney disease, and morbid obesity, and that he required one-person assist with personal hygiene. His MDS showed substantial/maximal assistance for personal hygiene and grooming, and he was observed with long fingernails filled beyond the fingertips with brown and black substances; he stated he wanted his fingernails cleaned and cut and that no one offers to cut or clean them. The DON stated that nail care is part of grooming care for residents.
Call Lights Not Kept Within Reach and ADL Grooming Not Provided
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene, and it also failed to keep call lights within reach for multiple residents. The deficiency involved 5 of 21 residents reviewed for accommodation of needs out of a sample of 25, including residents observed in bed or in a wheelchair without access to a call light and one resident with long facial hair who had not been shaved despite needing assistance. R15 was observed in bed with a call pendant in the windowsill and no call light plugged into the wall, and RN D stated the pendant should not have been there and that R15 could not reach it. R41 was observed in bed with the call light clipped to the cord hanging behind the bed and out of reach, with CNA E stating R41 did not have a pendant and should have access to the call light. R111 was observed with the call light wrapped around the bed while sitting in a wheelchair and unable to reach it, and CNA CC placed the call light near the resident so it was accessible. R24, who had diagnoses including dementia and neurocognitive disorder with lewy bodies and a care plan calling for 1-assist with personal hygiene and oral care, was observed with long facial hair and stated a desire to be clean shaved. CNA BB stated R24 preferred to be clean shaved, could use an electric razor with staff assistance, and needed staff help for all ADLs, but also noted the razor cord was missing and that may be why R24 had not been shaved. R75 was overheard yelling for help and stated he waited a long time for his call light to be answered; staff found no call light or pendant near him until the Housekeeping Director brought one and placed it around his neck. The DON stated residents should always have access to a call light and that all residents should have access to a bracelet, necklace pendant, or wall call light.
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