Failure to Provide Timely Incontinence Care and Scheduled Bathing, with Falsified ADL Documentation
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and scheduled bathing/showering for multiple residents who required assistance with activities of daily living. For one resident with spinal stenosis, muscle weakness, repeated falls, and schizoaffective disorder, the admission MDS documented total dependence or extensive assistance needs for toileting and hygiene, and the care plan required prompt response to needs and one‑to‑two staff assistance for toileting. Staff interviews revealed that when this resident requested to be changed during a meal service, CNAs and an LPN told him they could not provide incontinence care during tray pass due to a facility policy of “no patient care during meal passes.” The resident’s call light was turned off, he turned it back on, and ultimately removed his soiled brief and threw it into the hallway. Staff confirmed they delayed his incontinence care until after meal service. Other residents reported they were told they had to wait until after meals to be changed, and that they were not changed in the morning before breakfast despite being incontinent. Another resident with COPD, muscle weakness, and frequent bowel and bladder incontinence, who used a motorized wheelchair and was dependent for toileting hygiene, was care planned to be checked and changed every two hours and as needed. On the morning of observation, this resident was found in an electric wheelchair with pants saturated with urine and reported not having been changed since the start of the CNA’s shift at 7:00 a.m. because staff were doing breakfast and were “not allowed” to change residents during meals. Later that afternoon, observation of incontinence care showed the resident’s pants and chair pad were heavily soiled with urine and stool, and stool was present on the resident’s side and peri area. The primary CNA confirmed the last check/change had been around 9:00 a.m. and stated she usually waited for the resident to request changes, while the resident reported being unable to sense incontinence and that some CNAs did not routinely check her. Physical findings included deep red inner buttocks and creasing of the buttocks and thighs from prolonged sitting without movement. The facility also failed to provide scheduled showers or baths to several residents and had documentation irregularities. One cognitively intact resident, frequently incontinent and dependent for bathing, was scheduled for showers twice weekly but had multiple dates over several months with no shower record and no indication of being offered or receiving a bath or shower; the DON confirmed that on those dates the resident would not have received or been offered bathing as scheduled. Another cognitively intact resident requiring substantial assistance with bathing reported not receiving scheduled showers consistently, stating staff said there was not enough staff; shower records showed multiple missed or not‑offered showers on scheduled days, which the DON verified as accurate. A third resident, dependent for bathing and recently hospitalized, reported begging for a bath for several days, stated she only received about one shower a month, and complained of being offered showers in the middle of the night. Review of shower sheets showed a shower documented on a date when she was hospitalized, and a later bed bath entry bearing a CNA’s forged signature; the DON and the CNA confirmed the resident was not in the facility on the documented date and that the CNA had not signed the later record. A further resident with systemic lupus erythematosus, cerebral palsy, and muscle weakness, who required substantial assistance for bathing and was scheduled for twice‑weekly showers, reported not having a shower in three weeks and attributed this to hot water issues. Observation noted very oily hair. Shower sheets showed two recent entries indicating the resident refused showers, both signed with a CNA’s name and an illegible nurse signature. During review, the CNA whose name appeared on the forms stated the resident had never refused on those dates, denied the signatures were hers, and pointed out that the signatures did not match her known signature from a prior date. The DON confirmed that residents should receive at least two showers or baths per week, that lack of hot water would not constitute a refusal, and that no staff member should sign for a CNA who did not provide the care. These findings collectively demonstrate failures to provide timely incontinence care and scheduled bathing, as well as inaccurate and falsified documentation of ADL care.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.