Failure to Provide Daily Hygiene and Clothing Changes for Dependent Residents
Penalty
Summary
Facility staff failed to provide adequate assistance with activities of daily living (ADLs), specifically personal hygiene, grooming, and clothing changes, for three cognitively impaired residents. For one resident, the Quarterly MDS dated 12/02/25 documented severe cognitive impairment, no behaviors or care refusals, and independence with ADLs, with a care plan directive for staff to monitor and remove facial hair as needed. Despite this, repeated observations from 01/11/26 through 01/14/26 showed the resident consistently had long facial hair, indicating that staff did not follow the care plan related to grooming. A second resident’s admission MDS showed severe cognitive impairment, no behaviors or refusals, and a need for extensive assistance with hygiene, dressing, and bathing, with a care plan dated 12/02/25 directing staff to provide assistance from two staff for all ADLs and to provide clean, appropriate clothing daily. Observations over four consecutive days showed this resident wearing the same grey sweatshirt and having long facial hair. A third resident’s Quarterly MDS documented severe cognitive impairment, no behaviors or refusals, independence with dressing, and moderate assistance needed for hygiene and bathing, with a care plan dated 09/26/25 requiring supervision and assistance for all ADLs and clean clothing daily. Observations over multiple days showed this resident wearing the same green sweatsuit and having long facial hair. In interviews, an LPN, the DON, and the Administrator each stated that aides are responsible for assisting residents with changing clothes and shaving, that charge nurses are responsible for ensuring these cares are completed, and that they were not aware these residents’ clothes were not changed and their faces not shaved, despite expectations for daily clothing changes and shaving as needed, particularly with showers and with documentation of any refusals.
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