Failure to Provide Timely Incontinence Care and Checks for Dependent Residents
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and checks, as care planned, for residents who were unable to manage their own toileting and hygiene. One resident with dementia and psychotic disturbance was care planned as always incontinent of bowel and bladder, dependent on staff for toileting hygiene, and requiring substantial/maximal assistance for transfers. Her care plan directed staff to change soiled clothing after each incontinent episode and to provide incontinence care during rounds and as needed. On the day in question, she was observed seated in her wheelchair in the dining room from mid-afternoon through early evening, then moved by a CNA from the dining room to a common area without any incontinence check. She remained in the common area until nearly 8:00 p.m. with no staff providing incontinence checks or care during that time. When two CNAs transferred this resident to bed at approximately 7:55 p.m., they found her incontinence brief and shorts saturated with urine. Both CNAs confirmed the saturation and stated that she should have been changed at least every two hours and should not have been that wet, noting that she was usually dry at bedtime and was not a heavy wetter. The CNA assigned to her from 6:00 a.m. to 6:00 p.m. confirmed that the last incontinence care she provided was sometime before 3:30 p.m. and acknowledged that incontinence care should be provided every two hours and as needed. Another CNA confirmed she moved the resident from the dining room to the common area without performing an incontinence check, despite knowing the resident was incontinent and that incontinence care should be provided every two hours and as needed. A second resident, cognitively intact with a history of cerebrovascular disease, generalized muscle weakness, and hemiplegia/hemiparesis, was care planned as frequently incontinent of bowel and bladder, dependent on staff for toileting hygiene and transfers, with instructions to change soiled clothing after each incontinent episode and to check at least every two hours and as needed. This resident reported that night shift staff got her up daily around 4:00 a.m. and that she had not been changed since getting out of bed that morning, stating she needed to be changed. She reported that day shift CNAs did not provide incontinence care every two hours or when needed, and that they typically only changed her when putting her back to bed in the afternoon. She also stated she had requested two briefs be put on her because she knew how long she would sit without being changed and that she wanted staff to check her every two hours because she did not always know when she had urinated or had a bowel movement. When two CNAs transferred this resident to bed in the afternoon via Hoyer lift, they found she was wearing two incontinence briefs, both saturated with urine, with her pants also saturated and a bowel movement present. The day-shift CNA assigned to her confirmed the resident was always incontinent, required a Hoyer lift, had been up in her wheelchair when the CNA arrived for her shift, and had not received incontinence care during that shift until the 3:42 p.m. transfer. She stated incontinence rounds should have been conducted every two hours, that the resident had not refused care, that the resident should not have been double briefed, and that on each shift she never checked or changed the resident before 1:00 p.m. The night-shift CNA confirmed she double briefed the resident that morning, acknowledged she should not have placed two briefs on any resident, and stated she did so to try to prevent the resident’s clothing from being soiled by 8:00 a.m. On the following morning, the same resident reported again that night shift had gotten her up with a Hoyer lift at 4:00 a.m., changed her brief before getting her up, and that she had not been changed since, stating she needed to be changed. Her watch, which she used to track time, showed accurate time. When two CNAs transferred her to bed around 8:31 a.m. to provide incontinence care, they found her urine had saturated through her incontinence brief, pants, lift pad, and wheelchair cushion, requiring replacement of the cushion. Multiple CNAs and LPNs, as well as the ADON and DON, stated that incontinence rounds and checks should occur at least every two hours and as needed, and confirmed that both residents were incontinent and dependent on staff for toileting and transfers. Despite these expectations and care plan directives, the documented observations and interviews showed prolonged periods without incontinence checks or care, double briefing, and residents remaining in saturated briefs and clothing.
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.
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