F0656

G

Failure to Develop and Implement Resident-Specific Care Plans for ADL Refusals, ROM, and Nail/Oral Care

Rome, Georgia Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, resident-specific care plans addressing all identified needs, including refusals of care, range of motion (ROM), and nail and oral care. For one resident with Alzheimer’s disease, major depressive disorder, generalized anxiety disorder, schizoaffective disorder, osteoarthritis, and gait/mobility abnormalities, the quarterly MDS showed severe cognitive impairment with an inability to complete the BIMS interview. Despite this, the care plan did not include interventions for intermittent verbalization or refusal of ADL care. On the morning of 1/13/2026, a CNA reported that when she entered this resident’s room, the resident was already agitated, and during an attempt to assist with ADL care, the resident slid from the wheelchair onto the floor. Progress notes documented a witnessed fall while the resident was being adjusted in the wheelchair, resulting in a supracondylar fracture of the right femur.

For a second resident with aphasia following cerebral infarction, quadriplegia related to CVA, hand contractures, multiple-site muscle contractures, and type 2 diabetes, observations on multiple dates showed the resident lying on his back with both hands tightly closed in fists and no splints or rolls in place. During AM care, staff did not wash the resident’s hands or provide mouth or foot care, and when socks were removed, the great toe nail was thickened with debris buildup and yellowish discoloration. The MDS documented severe impairment in decision-making and total dependence on staff for personal hygiene, including nail care. The care plan identified dependence for dressing, oral hygiene, personal hygiene, and bathing, and directed staff to check nails for cleanliness, but contained no interventions for upper extremity contractures or ROM. An LPN confirmed there were no resident-specific interventions for nail care, no care plan for contractures, and no documentation of care refusal or attempted interventions.

For a third resident with vascular dementia, emphysema, and COPD, observations showed long, jagged fingernails and overgrown toenails on both feet that were curling into the skin, cloudy/tan in color, and curling up on the sides, pulling away from the nailbed. The admission MDS showed moderate cognitive impairment and a need for staff assistance with setup/cleanup for personal hygiene. The care plan, initiated after a decline in ADL self-care related to recent hospitalization, stated that staff should check nails and ensure they are clean and that the resident required staff assistance for ADL care. Interviews with CNAs revealed inconsistent understanding of who was responsible for nail care, with one CNA stating she usually did nail care during showers but not toenails, and another stating she trimmed the resident’s nails, that it was painful for the resident, and that she did not know who normally trimmed the resident’s nails. The DHS and an LPN acknowledged that the resident did not have resident-specific interventions for nail care and that there was no documentation of refusal of care or attempted care-planned interventions, despite facility policies requiring comprehensive, resident-specific care plans and timely updates with changes in condition.