Failure to Provide and Document Routine Bathing per ADL Care Plans and Resident Preferences
Summary
The deficiency involves the facility’s failure to provide and document bathing assistance for multiple residents in accordance with their ADL care plans and stated preferences. Facility policy required that residents receive assistance with ADLs, including bathing, every shift as appropriate. For one resident with dementia and a history of stroke who was severely cognitively impaired and required staff assistance for bathing and grooming, the ADL care plan indicated staff participation for bathing and did not note routine refusals. However, ADL documentation over a 30‑day period showed only one recorded bathing refusal and no other entries indicating that the resident had been bathed or had refused additional bathing during that time. Another resident with schizophrenia and depression, who was cognitively intact and required staff assistance with bathing, had an ADL care plan requiring staff participation with bathing and no indication of a tendency to refuse. Review of 30 days of ADL documentation revealed no evidence that this resident had been bathed and no recorded refusals. A third cognitively intact resident with type 2 diabetes and heart failure had an ADL care plan requiring staff participation with bathing, but ADL documentation showed only one bath in the most recent 30 days and no refusals. A fourth cognitively intact resident with spastic hemiplegic cerebral palsy had no bathing care plan in the record, and 30 days of ADL documentation contained no evidence of any baths or refusals. During a group interview, three cognitively intact residents reported they never received more than one bath per week and had not been bathed according to their preferences, which were to be bathed twice weekly. One resident stated they had just been bathed but had not received a bath for three weeks prior and believed they smelled due to the lack of regular bathing. Another resident reported it had been two weeks since the last bath and that a family member had taken them home to bathe a few days earlier. A third resident reported not having received a bath in a while. In an interview, the administrator, assistant administrator, and DON confirmed that documentation could not be located to show that these residents had been consistently bathed according to their preferences and acknowledged that the expectation was for consistent bathing with documentation of care and any refusals.
Penalty
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The facility failed to provide adequate ADL assistance, specifically nail care, to two residents who required staff support. One cognitively intact resident with diabetes, legal blindness, and adult failure to thrive needed partial/moderate help with bathing and personal hygiene and was observed on consecutive days with fingernails about one half inch long, which he stated interfered with using his TV remote; staff acknowledged the nails needed trimming but no assistance was provided by the next day. Another resident with anoxic brain damage and in a persistent vegetative state, fully dependent for all ADLs and with impaired ROM in all extremities, was observed with fingernails about one quarter inch long, and an LPN confirmed they needed trimming. These conditions occurred despite a facility policy stating that routine daily care includes assistance with ADLs.
A resident who was totally dependent on staff for ADLs, with significant medical conditions including respiratory failure, paraplegia, and anoxic brain damage, had care plans and orders requiring daily nail checks and twice-daily oral care. Surveyors observed that the resident was non-interviewable, with brown-appearing teeth, a white rough layer on the tongue consistent with thrush, and fingernails extending one to two centimeters beyond the fingertips and curling downward. The ADON confirmed these observations, showing that ordered oral and nail care were not adequately provided.
Surveyors found that two residents with severe cognitive deficits and multiple chronic conditions, both dependent on staff for personal hygiene per their MDS and care plans, had long, jagged, and visibly dirty fingernails with brown material under the nail beds on repeated observations. Care plans for ADL self-care deficits and altered ADL function included staff responsibility for checking, trimming, cleaning nails, and assisting with ADLs, yet these interventions were not carried out. The DON confirmed the poor nail condition for both residents, and the LNHA acknowledged there was no facility policy addressing nail care.
The facility failed to provide and/or document scheduled bathing and grooming for multiple dependent residents. One hospice resident with severe cognitive impairment and extensive ADL needs had only sporadic bed baths and showers documented, with no evidence of hair washing, nail care, or beard grooming, and was observed with greasy hair, unkempt facial hair, and long jagged nails amid conflicting statements between CNAs and a Hospice CNA about responsibility for care. Another cognitively impaired resident dependent for showering reported only weekly showers despite being scheduled for twice-weekly showers, and records showed several missed showers without refusals documented. Two additional cognitively intact residents requiring substantial assistance with bathing had incomplete shower documentation, with only some scheduled baths recorded and no evidence of refusals, despite staff acknowledging that shower sheets should be completed for all showers, bed baths, or refusals and a policy requiring provision of ADL care including bathing and grooming.
A resident with severe cognitive impairment, total incontinence, and multiple comorbidities was left in stool and urine for an extended period when CNAs were unclear about assignment coverage during a short-staffed morning shift. The resident’s room smelled of stool, and although an LPN entered to apply powder under the breasts, incontinence care was not provided until later, when a CNA discovered a large bowel movement soiling the perineal area, bed pad, and sheet. Upon cleaning, staff observed red, open thigh creases and deep red, excoriated skin over the buttocks extending to the lower back, despite a care plan requiring regular incontinence checks and perineal cleansing.
Multiple dependent residents did not receive necessary ADL assistance with bathing, nail care, personal hygiene, and eating as outlined in their care plans and facility policy. Several residents with cognitive impairment, hemiplegia, dysphagia, and other serious conditions went extended periods with only one or two baths or showers, or had no documented bathing at all, despite a twice‑weekly bathing expectation. Some residents were repeatedly observed with long fingernails and visible brown or dark material underneath, even though nail care was ordered with showers and a facility nail‑care policy required cleaning and trimming. One resident who was dependent for eating and at risk for altered nutrition was not offered a dinner tray during an observed meal service and therefore received no feeding assistance at that meal, despite an order for a mechanical soft diet with thin liquids. Staff interviews and record reviews confirmed missed or undocumented showers, lack of nail care, and failure to offer a meal, affecting multiple residents who relied on staff for ADLs.
Failure to Provide Adequate Nail Care as Part of ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically nail care, for residents who were unable to perform these tasks independently. One resident with type 2 diabetes mellitus, legal blindness, and adult failure to thrive had an MDS assessment indicating intact cognition but a need for partial/moderate assistance with bathing and personal hygiene. On observation, this resident’s fingernails were long, extending approximately one half inch beyond the fingertips. The resident reported disliking the length of his fingernails because it interfered with his ability to press buttons on his TV remote. The Activity Director confirmed that the fingernails were long and needed trimming. A subsequent observation the next day showed the fingernails remained long, and the resident confirmed that no one had offered to cut his fingernails since the prior day. Another resident, admitted with anoxic brain damage, persistent vegetative state, and type 2 diabetes mellitus, had an MDS assessment indicating a persistent vegetative state with no discernible consciousness, dependence on staff for all ADLs, and impaired range of motion in all extremities. During an observation with an LPN, this resident’s fingernails were noted to be long, extending approximately one quarter inch beyond the fingertips, and the LPN verified that the fingernails were long and needed trimming. Review of the facility’s undated “Routine Resident Care” policy showed that the facility was responsible for providing routine daily care, including assistance with ADLs. The failure to ensure nail care for these residents constituted noncompliance and was investigated under multiple complaint numbers.
Failure to Provide Adequate Oral and Nail Care for a Dependent Resident
Penalty
Summary
The facility failed to provide appropriate oral and nail care for a totally dependent resident. The resident was admitted with respiratory failure, paraplegia, and anoxic brain damage, and his care plan documented that he was totally dependent on staff for ADLs and that his nails should be checked daily for length and cleanliness. His MDS assessment indicated he was never or rarely understood, dependent on staff for ADL care, and that his mouth could not be assessed for dental problems, and physician orders required oral care twice daily with no orders for thrush treatment. During observation, the resident was non-interviewable with his mouth hanging open, his teeth appearing brown, and a white rough layer visible on his tongue consistent with thrush, and his fingernails extended approximately one to two centimeters beyond the fingertips and curled downward. The ADON confirmed these findings, demonstrating that ordered and care-planned oral and nail care were not being adequately provided to this dependent resident.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary nail care for residents who were dependent on staff for activities of daily living (ADLs), specifically personal hygiene. One resident with severe cognitive impairment, multiple diagnoses including neuropathy, peripheral vascular disease, vascular dementia, cerebrovascular accident, and other chronic conditions had a care plan intervention directing staff to check nail length and trim and clean nails on bath day and as necessary. Despite this, surveyor observations on two consecutive days showed the resident’s nails were long, jagged, and had a brown substance under the nail bed. The DON confirmed during interview that the resident’s nails were in need of nail care. Another resident, also with severe cognitive impairment and multiple diagnoses including hypertensive heart disease, atrial fibrillation, dementia with anxiety, Alzheimer’s disease, psychosis, and gastrointestinal conditions, had a care plan for altered ADL function. Interventions included providing set-up, supervision, cues, and assistance through completion of ADLs, encouraging participation at the resident’s optimal level, and providing oral care daily and as needed. The MDS indicated the resident was dependent on staff for toileting and personal hygiene and did not reject care. However, surveyor observations on two consecutive days found this resident’s nails were long, jagged, and dirty with a brown substance under the nails. The DON verified that the nails were in need of care, and the LNHA reported that the facility had no policy related to care of residents’ nails. This deficiency was cited under a complaint investigation.
Failure to Provide and Document Scheduled Bathing and Grooming for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure dependent residents received appropriate bathing, showers, grooming, and fingernail care in accordance with their assessed needs, care plans, and facility policy. One resident with severe cognitive impairment, multiple complex diagnoses, and on Hospice care required substantial to maximal assistance with ADLs and was care planned for showers on specific days with assistance for bathing and grooming. Documentation showed only intermittent bed baths and showers, with no recorded refusals, and no evidence of hair washing, fingernail clipping, or beard grooming. On observation, this resident was noted to have greasy long hair, unkempt facial hair, and long jagged fingernails. CNAs stated Hospice was responsible for showers and hair care, while the Hospice CNA stated facility CNAs were responsible, and confirmed the resident’s unkempt condition. Another resident with severe cognitive impairment, dependence on others for showering and personal hygiene, and multiple medical conditions reported only receiving showers once a week and wanting more frequent showers. Facility shower sheets and nurse aide task checklists showed showers were scheduled twice weekly, but documentation reflected that showers were only completed on some of the scheduled days, with only one documented refusal. The Interim DON confirmed that shower sheets were expected to be completed for each scheduled shower day, regardless of whether the resident accepted a shower, received a bed bath, or refused, and verified there was no evidence that several scheduled showers had been provided. Two additional residents, both cognitively intact and requiring substantial to maximal assistance with bathing, also lacked documented showers according to their schedules. For one resident, who was dependent for mobility and ADLs, shower sheets showed bathing on only three of eight scheduled opportunities, with no documentation of refusals in nursing notes. For the other resident, admitted and discharged within the review period, shower sheets showed no evidence of showers during the initial days after admission, including a scheduled shower day, and staff interviews confirmed that shower sheets should be completed for all showers, bed baths, or refusals. The IDON and other staff confirmed that the facility had no additional documentation to show that these residents were offered or received scheduled bathing, despite a facility policy stating that ADL care and services, including bathing, dressing, grooming, and oral care, would be provided.
Failure to Provide Timely Incontinence Care Resulting in Prolonged Soiling
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who was always incontinent of bowel and bladder and required extensive assistance with mobility and transfers. The resident, admitted with diagnoses including chronic kidney disease, muscle weakness, overactive bladder, anxiety disorder, and polyneuropathy, was care planned to be checked as required for incontinence and to have the perineum washed, rinsed, and dried. On the morning in question, surveyors observed the resident awake in bed in a room that smelled of stool; the resident stated she had “pooped a little” and that a staff member had said she would return shortly. Later that morning, an LPN entered the room only to apply powder under the resident’s breasts and then left, without addressing the incontinence. At approximately 10:00 A.M., a CNA providing incontinence care found the resident with a large bowel movement extending into the perineal area, with the bed pad and sheet soiled with stool and urine. After the stool was removed, the resident’s bilateral thigh creases were observed to be red and open along the crease lines, and the buttocks were deep red and excoriated over the entire buttocks to the lower back. The CNA reported she had started her shift at 8:00 A.M. and had not yet seen the resident, as another staff member was supposed to cover until her arrival. Another CNA, who started at 6:30 A.M., stated there had been a call-off and only two CNAs on duty, and she did not realize she was assigned to cover this resident; although she delivered the resident’s breakfast tray, she did not check or change the resident and only told her someone would be with her. The DON stated residents should be checked for incontinence at least every two hours and changed immediately if lying in stool.
Failure to Provide Required ADL Assistance With Bathing, Nail Care, and Eating
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs)—including bathing, nail care, personal hygiene, and eating—to multiple dependent residents, as required by their care plans and facility policy. One resident with cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, osteoarthritis, memory problems, and total dependence for showers and personal hygiene received only one bed bath and one shower over an 18‑day stay, despite a facility expectation of twice‑weekly bathing. Another resident with hemiplegia, dysphagia post‑stroke, aphasia, memory problems, and total dependence for bathing and personal hygiene was observed on several days with a very dry bottom lip and later with long fingernails containing a dark substance underneath. Although his care plan called for assistance with all ADLs, nail care, hair shampooing with showers, and oral care twice daily, the CNA who provided his shower documented no nail care and confirmed that his nails were not cleaned or trimmed. A resident with hemiplegia, hemiparesis, cognitive communication deficit, reduced mobility, cerebral infarction, severe cognitive impairment, and dependence on staff for eating, personal hygiene, transfers, and bathing was not offered a dinner meal during a continuous observation of the hall dining service, and therefore did not receive feeding assistance at that meal. A CNA stated that no residents refused dinner, while the resident confirmed she was not offered a tray but said she would have refused if it had been offered; the Administrator asserted that the CNA had offered the meal and that the resident refused. The same resident’s care plan identified risk for altered nutrition status and required that her ordered mechanical soft diet with thin liquids be provided, and that she receive assistance with ADLs and scheduled showers. Review of shower documentation and the shower schedule showed she received six showers over a period when ten were scheduled, and staff confirmed she did not refuse showers and that all showers would be documented. Additional residents were found with unmet ADL needs related to grooming and hygiene. One resident with cerebral infarction, muscle weakness, vascular dementia, moderate cognitive impairment, and dependence on staff for personal hygiene had long fingernails with brown substance caked underneath on multiple observations, despite a care plan approach to provide nail care with showers; the resident stated he preferred short, clean nails, and staff confirmed he did not refuse care. Another resident with COPD, metabolic encephalopathy, diabetes, depression, CHF, hypertension, fibromyalgia, cognitive communication deficit, severe cognitive impairment, incontinence, and dependence for showers and substantial assistance with hygiene was repeatedly observed over several days with long fingernails and brown substance underneath, despite a facility nail care policy requiring cleaning and trimming to maintain well‑being. A discharged resident with multiple fractures, osteoporosis, COPD, and chronic respiratory failure, who required supervision or touching assistance with bathing and was frequently incontinent, had no documented baths or showers during her stay, which the Administrator confirmed. A further resident with impaired cognition and moderate assistance needs for bathing, toileting, and mobility received showers only every other week according to facility records, and the Regional Nurse Consultant confirmed she received only one shower per week, even though she had declined some offers, resulting in less frequent bathing than the facility’s twice‑weekly expectation. Overall, record reviews, observations, interviews, and policy review showed that seven residents who were unable to carry out ADLs did not consistently receive necessary care and services to maintain good nutrition, grooming, and personal hygiene. Deficiencies included missed or undocumented showers and baths, lack of nail care despite visible buildup under long nails, failure to provide ordered diet and feeding assistance at a meal, and inadequate attention to oral and lip care, all in residents whose care plans and assessments documented dependence on staff for these ADLs and a facility standard of twice‑weekly bathing and routine nail care.
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