Failure to Provide Resident Opportunity for Toileting
Summary
A resident with a history of right femur fracture, muscle wasting, atrophy, and cognitive impairment was re-admitted to the facility and required moderate assistance for transfers. The resident was frequently incontinent of bladder and bowel and had a care plan in place that included a toileting program and interventions to maintain cleanliness and monitor elimination. On the evening in question, video footage showed the resident requesting to use the bathroom, but the assigned CNA did not assist her to the toilet. Instead, the CNA instructed the resident to urinate in her incontinence brief, stating it was difficult for her to use the toilet due to her leg injury and that she would be cleaned up afterward. The CNA later confirmed in an interview that he did not redirect the resident appropriately and opted to have her use the brief because he was about to change her. The care plan interventions, which included providing opportunities for toileting, were not followed, and the resident was not given the chance to maintain her ability to perform activities of daily living related to toileting. This incident was identified through record review, policy review, video evidence, and staff interviews, and it affected one resident out of four reviewed for change in condition.
Penalty
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Failure to provide adequate visual assistance for meal selection. A resident with severe vision loss, including blindness in one eye and macular degeneration in the other, was observed struggling to read a weekly menu using two very small magnifying glasses. Records showed highly impaired vision, but the care plan did not fully reflect the resident’s blindness, and staff interviews showed inconsistent awareness of his needs. The resident stated no one had offered a larger magnifier or helped him select meals, despite a policy requiring accessible communication and assistance for persons with low vision.
A resident with bilateral conductive hearing loss and intact cognition had a care plan requiring a communication board, but staff repeatedly communicated verbally without using it. During observations, CNAs and another staff member spoke to the resident about care needs and comfort items, yet the resident stated he did not understand what was being said and wanted staff to use the whiteboard. The resident was also observed without a whiteboard or notepad available in the dining room, and the DON confirmed staff should have used written communication.
A resident with chronic respiratory failure, encephalopathy, sepsis, a trach, G-tube, and foley was dependent for multiple ADLs and required 2- to 3-person assist for turning. During incontinent care, a CNA provided care alone instead of the required 2-person assistance, while the resident coughed intermittently. The CNA said the other staff member was busy, and the RNS and DON confirmed the resident needed at least two staff for turning and incontinent care per the task list and care plan.
Failure to Provide Needed ADL Assistance and Supervision: A resident with dementia and severe cognitive impairment was assessed as needing supervision or touching assistance with dressing, hygiene, and bathing, but was repeatedly observed wearing the same outfit over multiple days. CNA and LVN interviews showed the resident was documented as independent with ADLs despite the DON stating she required supervision/assistance and had a history of refusing care that was not care planned. The resident’s closet was nearly empty, and staff did not report that she refused dressing assistance during the shift reviewed.
Facility staff failed to provide or offer scheduled showers or bed baths to a cognitively intact resident who required partial/moderate assistance with bathing. Although the shower schedule listed bathing on specific weekdays during the day shift, ADL documentation over multiple days showed entries coded as not applicable or not attempted, with some shifts left blank, and no evidence that bathing was provided or offered. A CNA who routinely cared for the resident confirmed the scheduled shower days and, upon review of the ADL records, acknowledged not knowing why the resident did not receive showers or bed baths and that there was no documentation that these were offered.
Failure to address a resident’s hearing needs and hearing aid use. A resident with diagnoses including metabolic encephalopathy and repeated falls reported using hearing aids at home, but the aids were left there before admission. Staff observed the resident could hear only when spoken to in a raised voice, and a provider note documented significant hearing impairment with repeated requests for clarification. The care plan did not include hearing or hearing aid use, and an RCM/LPN and the QA director acknowledged the resident’s hearing needs were not addressed in the plan of care.
Failure to Provide Adequate Visual Assistance for Meal Selection
Penalty
Summary
The facility failed to ensure services and assistance were provided to preserve the independence of a resident with highly impaired vision. The resident’s significant change MDS dated 4/16/26 indicated intact cognition, clear speech, and that he was understood and able to understand, but also showed highly impaired vision. The resident was independent in some ADLs, dependent in others, and able to walk short distances such as to the bathroom. His care plan identified impaired visual function related to macular degeneration and stated he could see very large print/newspaper headlines with a magnifying glass and glasses, but it did not identify blindness in his left eye. Records reviewed showed the resident had age-related macular degeneration in the right eye and blindness in the left eye, with later provider documentation noting progressive vision loss, blindness in the left eye from a prior injury, and severe macular degeneration in the right eye. During a care conference, the resident was noted to have blurry vision even with a magnifying glass. A progress note later documented that the social worker met with the resident about referral options for vision services and that the resident voiced interest in a referral to services for the blind. During observation, the resident was seen holding two very small magnifying glasses up to his right eye while trying to read a weekly menu printed in approximately 11-point font; the menu had to be held close to his nose for him to make out one or two words at a time. The resident stated no one had offered him a larger magnifying glass and that no one had ever asked him or helped him make meal selections before. Staff interviews showed inconsistent awareness of his impairment: one NA said staff were supposed to sit with him and go through the menu, while the cook, manager of nutrition and food services, social worker, and DON stated they were not aware of his visual impairment or how he was being assisted. The RN stated the resident used his own small magnifying glass, had not asked for help, and she had not approached him to ask how staff could assist him with meal selection. The facility’s auxiliary aids policy stated that persons who were blind or had low vision would be provided accessible communication and assistance, but the resident’s menu-reading support was not consistently provided or documented.
Failure to Use Communication Board for Resident With Hearing Loss
Penalty
Summary
The facility failed to ensure effective communication for a resident with bilateral conductive hearing loss and a BIMS score of 14. The resident’s care plan indicated a communication problem related to hearing deficit and oral deformity and stated that the resident required a communication board, with communication by writing, yes/no pointing, or pointing to what was written on the board. During interview, the resident stated that staff did not use a whiteboard, that he could not hear what staff said when they came into his room, and that this bothered him and made him mad. Survey observations showed multiple instances in which staff communicated verbally with the resident without using the communication board or notepad. A staff member told the resident she would return to change him, using hand gestures, and the resident later stated he did not understand what was said. A CNA asked the resident questions about a blanket and whether he was okay, but the resident did not respond and later stated he had not understood and wanted staff to use the whiteboard. Another CNA asked if he was ready to get up for lunch and later told him she was going to clean him up and raise the bed, again without using written communication. At one point, the resident was observed in the dining room without a whiteboard or notepad available for communication. The DON stated staff should have been using the whiteboard or a notepad to communicate in writing with the resident.
Failure to Provide Required Two-Person Assistance During Incontinent Care
Penalty
Summary
The facility failed to ensure that one sampled resident received safe and adequate assistance with activities of daily living when incontinent care was provided by only one staff member instead of the required two-person assistance. Resident 37 was admitted and readmitted to the facility with diagnoses including chronic respiratory failure, encephalopathy, and sepsis. The resident's H&P indicated the resident did not have the ability to understand and make decisions and had a tracheostomy, G-tube, and foley catheter. The MDS indicated the resident's cognitive skills for daily decision making were severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, showering, personal hygiene, and rolling left and right. The resident's Task List Report indicated two- to three-person assist as needed during turning to maintain spine alignment. During observation, a CNA provided incontinent care alone while supporting the resident's left side and buttock with one hand and cleaning, changing the brief, and replacing linens with the other hand for about 10 minutes. The resident was observed coughing intermittently during the care. The CNA stated the resident was typically provided incontinent care by two staff members, but the other staff member was busy, so she performed the care alone. The RNS and DON both stated the resident required at least two-person assistance for turning and incontinent care, and the facility's policies indicated staff should use sufficient assistance as reflected in the resident's plan of care and provide care according to the assessed level.
Failure to Provide Needed ADL Assistance and Supervision
Penalty
Summary
The facility failed to provide necessary care and services to support activities of daily living for Resident 36, who had dementia and a February 19, 2026 MDS indicating severe cognitive impairment with a BIM score of 03. The MDS also showed the resident needed supervision or touching assistance with oral hygiene, showering/bathing, upper body dressing, lower body dressing, and personal hygiene. The resident’s care plan, dated May 14, 2025, identified ADL needs related to altered mental status and dementia and stated staff should anticipate and meet needs, but there was no documented evidence that the resident’s refusal of ADL assistance was identified and addressed. During observations from April 20 through April 22, 2026, Resident 36 was repeatedly seen wearing the same matching blue printed flannel top and bottom. On April 20 and April 21, the resident was observed ambulating in the hallway with a FWW and stated she had not yet received her lunch tray. On April 22, the resident was observed in the morning wearing the same outfit, searching for a snack, and later asleep in her room still dressed in the same clothing. When asked about having another set of clothes, the resident stated, "I do not know," and walked away. Interviews and record review showed CNA 10 stated she did not help the resident get dressed that morning and could not recall whether the resident had been wearing the same outfit when she arrived. CNA 10 also found the resident’s closet empty except for two knitted sweaters. LVN 2 stated the resident had a history of refusing ADL assistance, including showers, but no report was received that she refused services that day. CNA 11 stated the CNAs documented the resident as independent with ADLs during the period reviewed, while the DON stated the resident was confused and forgetful, staff should report missing clothing, and the resident should have been supervised and/or assisted with ADLs. The DON also stated the resident’s refusal behaviors should have been care planned, but there was no care plan developed or initiated to address them.
Failure to Provide Scheduled Showers/Bed Baths and ADL Support
Penalty
Summary
Facility staff failed to ensure that a resident did not lose the ability to perform activities of daily living (ADLs) by not providing or offering showers or bed baths as scheduled. The resident was admitted with diagnoses including muscle weakness and, on the most recent MDS admission assessment with an ARD of 03/19/2026, scored 15/15 on the BIMS, indicating intact cognition for daily decision-making. Section GG of the MDS coded the resident as requiring partial/moderate assistance for showering/bathing. The facility’s 200 Wing Shower List showed the resident was scheduled for showers on Mondays and Thursdays during the 7:00 a.m. – 3:00 p.m. shift. However, review of the ADL documentation for March and April 2026 revealed multiple dates on which showering/bathing was coded as not applicable or not attempted, and there was no documentation that the resident received or was offered a shower or bed bath on those days. Specifically, the March 2026 ADL sheet showed that on 03/06/2026 the day shift was coded “09” (not applicable – not attempted and the resident did not perform this activity prior to the current illness), the evening shift “88” (not attempted due to medical condition or safety concerns), and the night shift “09.” On 03/23/2026, the day shift entry was left blank, and the evening and night shifts were both coded “09.” The April 2026 ADL sheet showed that on 04/13/2026 the day shift was coded “98,” the evening shift “88,” and the night shift “09,” and on 04/20/2026 all three shifts were coded “09.” During an interview on 04/23/2026, CNA #5, who provided care and showers to the resident and confirmed the scheduled Monday/Thursday shower days, stated she did not know why the resident did not receive showers or bed baths on the identified dates and acknowledged the resident should have been offered them. Upon review of the ADL sheets, CNA #5 confirmed there was no evidence that showers or bed baths were offered on those dates.
Failure to Address Hearing Needs and Hearing Aid Use
Penalty
Summary
The facility failed to ensure Resident 35 was assessed for hearing needs, obtained needed hearing devices, and had hearing device use included in the plan of care. Resident 35 was admitted with diagnoses including spondylosis with myelopathy, metabolic encephalopathy, and repeated falls, and was able to make needs known. During an interview and observation, Resident 35 stated they used hearing aids at home and had left them there before coming to the facility. Observation showed the resident could hear questions only when the speaker raised their voice to a soft yell. The plan of care initiated on 02/12/2026 did not include a focus area related to hearing or hearing aid use. A provider encounter note dated 02/20/2026 documented significant hearing impairment, with repeated questions and clarification needed during the interview and frequent requests for repetition due to hearing difficulties. During interviews, the RCM/LPN stated the resident was hard of hearing, required a raised voice to communicate, and would benefit from a device to increase hearing; the staff member also stated they were unaware the resident had hearing aids at home and that the facility should have reached out to obtain them. The RCM/LPN later stated the resident's hearing difficulties and hearing aid use should have been included in the plan of care. The Regional Director of QA stated the facility should have attempted to obtain the hearing aids and, if unsuccessful, referred the resident to a hearing specialist to obtain new hearing aids.
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