Failure to Provide Necessary Nail Care for Dependent Resident
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, specifically nail care, to a dependent resident with quadriplegia. The resident was admitted with diagnoses including unspecified quadriplegia, muscle wasting and atrophy, and other lack of coordination, and had documented ADL self-care performance deficits and impaired range of motion in all extremities. During an observation and interview, the resident’s fingernails were noted to be approximately one to one and a half inches long. The resident reported that he had been requesting nail trimming from his assigned CNA for the past three days, but was repeatedly told variations of “not yet” or that the CNA was on break or it was change of shift. He stated that his nails had last been cut by a family member about six weeks earlier, and that the DON had been informed of his request for nail trimming by a psychiatry provider. A telephone interview with the family member confirmed that she had last cut his nails approximately six weeks prior. Review of the resident’s nail care task documentation from 3/28/26 to 4/23/26 showed entries of “No Nail Care,” with one entry of “Resident Refused” on 3/30/26, and no evidence that nail care had been provided in the last 30 days. The assigned CNA stated that nail care was supposed to be completed every weekend or as needed, and that staff should perform nail care whenever a resident requested it, but also reported that staffing shortages delayed their ability to cut residents’ nails. She indicated that the resident’s nails were last cut about a month ago by a family member and that she planned to cut his nails that day because he had asked. The DON and RN/Unit Manager stated that CNAs or nurses provided nail care depending on diagnosis, that nail care should be done if a resident requested it, and that nail care was part of hygiene and infection control, but they were not sure where completion or refusal of nail care should be documented and could not confirm documentation of prior refusals. The facility did not provide a policy related to ADLs or nail care.
Plan Of Correction
Corrective Action for Resident Affected: Nail care was provided to Resident#4. Identification of Other Residents at Risk: Director of Nursing or designee conducted a house-wide audit to identify residents in need of nail care. Any identified concerns were addressed, and nail care services were provided as indicated. Systemic Changes Implemented: The Director of Nursing or designee re-educated the Licensed Nurses and certified Nursing assistants on resident nail care requirements, including timely identification and reporting of nail care needs. Licensed Nurses and Certified Nursing Assistants were educated on documenting completion of nail care in the electronic health record and communicating unmet care needs to nursing supervision. Monitoring to Ensure Compliance: The Director of Nursing or designee will conduct weekly audits of residents requiring nail care needs are addressed and documented appropriately. Random audits will be completed weekly for four weeks, then monthly for two months. Findings will be reviewed during the facility's Quality Assurance Committee meetings, until substantial compliance is met.
Penalty
Resources
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A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
A resident who was dependent on staff for toileting and required a Hoyer lift, as documented on the MDS, did not receive timely incontinence care after activating the call bell. The resident reported requesting assistance, and a staff member acknowledged the call bell and stated they would notify a nurse aide, but no one arrived to provide care during an observation period lasting over an hour. This delay occurred despite facility policy requiring support for ADLs and the DON’s acknowledgement that a 15-minute wait for call bell response was considered too long.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
A resident with urinary incontinence, vascular dementia, and intellectual disability was repeatedly observed lying in bed with wet clothing and bedding and a strong urine odor, remaining wet for extended periods despite staff statements that residents were checked every two hours and that this resident had not refused care. On another occasion, the same resident was found with multiple soaked incontinence pads, a soaked brief, wet clothing, and wet bed linens, and the CNA initially did not check for incontinence when the resident was sleeping until prompted. The CNA reported routinely placing two incontinence briefs on the resident, and two briefs were observed in use, even though the care plan did not direct the use of more than one brief and there was no documentation of care refusals on the dates in question.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs), specifically incontinence care, to a resident who was dependent on staff for these needs. Facility policy on ADL support, revised in April 2025, states that residents who are unable to carry out ADLs independently are to receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The resident’s Quarterly MDS dated March 4, 2026, documented that the resident required a Hoyer lift and was dependent on staff for showering/bathing and toileting. On the survey date, the resident reported during an interview at 11:12 a.m. that they required assistance with incontinence care and had activated their call bell at approximately 11:00 a.m. At 11:17 a.m., a staff member entered the room, acknowledged the call bell, and, upon being informed that the resident needed incontinence care, stated they would inform the nurse aide. By 11:35 a.m., when the interview concluded, no staff had come to provide the requested care. Continued observation from the nurses’ station between 11:35 a.m. and 12:03 p.m. showed that no staff responded to the resident’s call for incontinence assistance during that period. When questioned, the DON stated that a 15-minute wait time for call bell responses was considered too long, while the resident had been waiting for over an hour.
Plan Of Correction
Resident 1's call bell was responded to and incontinence care was provided on 4/14/2026. Facility wide audit of all residents who are dependent for toileting will be completed. Nursing staff will be educated on ASL policy. DON/Designee will complete ADL care audits daily x30 days then three times per week for 4 weeks to ensure proper ADL care is being provided. DON/Designee will report findings to QA Committee for review and recommendations.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Provide Timely Incontinence Care and Improper Use of Multiple Briefs
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and appropriate ADL assistance to a resident with urinary incontinence, as well as the inappropriate use of multiple incontinence briefs. On one date, surveyors observed the resident lying in bed with visibly wet pants and a noticeable urine odor in the room at midday. Over two hours later, the resident’s pants remained wet, with the wet area only beginning to fade. The CNA assigned to the resident stated he checked residents every two hours and had last checked this resident before lunch, and later reported he had just changed the resident and found him wet. The resident’s clinical record showed diagnoses including benign prostatic hyperplasia without lower urinary tract symptoms, vascular dementia, and intellectual disability, and the care plan directed staff to assist with routine toileting, check routinely for incontinence, provide incontinence care as needed, and encourage the resident to allow staff assistance when incontinent. On another date, the same resident was observed lying in bed with at least two incontinence pads under him and a visible ring of urine around him on the bed. Later observations that day showed an even darker ring of urine and an additional lighter, drying ring, with the resident remaining in the same position and the bed still wet. The CNA reported he had last changed the resident earlier that morning and that the resident had not refused care. During an ADL care observation, the CNA initially stopped at the door when he saw the resident sleeping and did not check for incontinence until prompted by the surveyor. When prompted to educate the resident and request permission to provide care, the resident got up and allowed the CNA to change him. At that time, the resident had two soaked incontinence pads, a soaked brief, a soaked red shirt, and soaked bed sheets, all of which were changed; the CNA then placed two incontinence briefs on the resident. The CNA stated he typically placed two briefs on this resident, although the care plan did not direct staff to use two briefs, and the Executive Director later confirmed staff should not place two briefs on a resident unless care planned. Documentation for the relevant dates did not show any refusals of care in the point-of-care records or progress notes, despite staff statements that the resident had not refused care.
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