F0677

E

Failure to Provide Necessary Nail and Skin Care for Dependent Residents

Brenham, Texas Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically nail and skin care, to residents who were unable to perform this care independently. For one resident with acute kidney failure, traumatic brain compression with herniation, blindness, and severe cognitive impairment, surveyors observed extremely thick, yellow-brown, distorted toenails extending past the tips of the toes, with brittle, curved nails growing away from the nail bed. The same resident’s feet had extremely dry, flaking, rough skin with thickened areas and discolored patches, as well as small red scabs on a toe. His fingernails extended approximately three-quarters of an inch past the fingertips with visible brown and black debris that appeared to be dirt. Despite these conditions, shower sheets for this resident documented that there was no dryness, abnormal color, abnormal skin, hardened skin, and that toenails did not need to be cut, and these assessments were signed by charge nurses.

Another resident, with chronic diastolic heart failure, morbid obesity, chronic kidney disease, and severe cognitive impairment, was also found with extremely thick, yellow-brown, elongated, brittle, curved, and distorted toenails on both feet, with nails growing outward away from the nail bed. His feet and lower legs had extremely dry, flaking skin with thick layers extending up to the shins, resembling fish scales and appearing as if the skin was cracking. His fingernails were approximately three-quarters of an inch past the fingertips, jagged and brittle, with dark brown material inside the nails that appeared to be dirt. Podiatry records documented nail dystrophy, nail thickening, elongated and discolored toenails, and thickened dystrophic nails with subungual debris on both feet, with a plan for follow-up in two months. However, multiple shower sheets for this resident also indicated no dryness, abnormal color, abnormal skin, hardened skin, and that toenails did not need to be cut, and were signed by charge nurses.

A third resident, with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage affecting the left dominant side and contractures of the left shoulder and elbow, had a care plan identifying an ADL self-care performance deficit requiring extensive assistance with personal hygiene and oral care. Observations showed this resident’s toenails extended past the tips of the toes, with big toenails about one-quarter inch past the tips and other toenails overly long and curved either toward the big toe or upward away from the nail bed. His fingernails were overly long, extended past the fingertips, jagged and uneven, and yellow in color. Two residents reported that their long fingernails bothered them; one stated his nails looked like fangs, were very dirty underneath, and that he wanted them clipped, and another stated his nails were too long, caught on his clothes, and poked him in the face, and that staff did not want to cut his nails. Multiple staff interviews confirmed that the residents’ nails were excessively long, dirty, and in poor condition, that these conditions were not documented or communicated as required, and that expectations for CNAs and nurses to assess, document, and trim nails or refer to podiatry were not followed, resulting in residents not receiving needed ADL care for grooming and hygiene.

Interviews with nursing staff and leadership further described inconsistent understanding and implementation of responsibilities for nail care. An LVN, when shown photos of one resident’s nails, acknowledged they should have been cut, described the feet as very dry and scaly, and stated that such conditions should be documented on a skin assessment. Another LVN, an agency nurse, reported having seen very long finger and toenails on a resident during a skin assessment but did not chart this, did not discuss nail care with the resident, and did not recall informing anyone, despite acknowledging that the facility’s expectation was to document, perform, or pass along the need for nail trimming. Another LVN stated she had been told nurses do not cut toenails and believed only the podiatrist did so, and that she had never been told she needed to cut resident toenails, only fingernails. In contrast, the Administrator stated that CNAs were expected to identify nail care needs and notify nurses, that nurses were expected to clip both finger and toenails, and that relying solely on the podiatrist for toenail trimming was not acceptable. The interim DON, upon viewing photos of residents’ nails and feet, stated she had not been aware of their condition, described the nails as dirty and the situation as unacceptable from an infection control and dignity standpoint, and indicated that head-to-toe skin assessments were expected to include feet and nails. These observations and interviews demonstrate that residents who were unable to perform ADLs did not receive necessary services to maintain grooming and personal hygiene, specifically clean and properly trimmed fingernails and toenails, despite facility policies stating that residents unable to carry out ADLs independently would receive appropriate care and services to maintain hygiene.

The facility’s own ADL policy stated that residents unable to carry out ADLs independently would be provided with care, treatment, and services to maintain or improve their ability to perform ADLs, including appropriate support and assistance with hygiene such as bathing, dressing, and grooming. A skin integrity policy stated the purpose was to ensure residents did not develop pressure ulcers or injuries unless clinically unavoidable and that the facility would provide care and services consistent with professional standards of practice. However, the documented shower assessments that repeatedly indicated no dryness, abnormal skin, or need for toenail trimming, in contrast with the observed conditions of thick, elongated, discolored, and dirty nails and severely dry, scaly skin, show that these policies were not followed in practice for the residents reviewed. The combination of inaccurate or incomplete documentation, failure to act on observed nail and skin conditions, and inconsistent understanding among staff about who was responsible for nail care led to residents not receiving necessary ADL assistance for grooming and personal hygiene.