Failure to provide fingernail care for a resident with DM and ESRD. The resident was cognitively intact, had long pointed fingernails with dark substance under them, and stated assistance was needed because of the DM diagnosis and that nail trimming had not been offered. The chart had no care plan direction for staff or an RN to trim the nails and no documentation that the task was completed; staff stated only an RN could perform the nail care for residents with DM.
Failure to Provide Adequate Nail Care: A resident who was cognitively impaired and dependent on staff for ADLs had dark, thick debris under the fingernails and around the cuticles on both hands over multiple observations. The care plan called for hygiene assistance, but the record lacked documentation of nail care, and staff, including CNAs, an LPN, and an RNCM, acknowledged the nails were dirty and that the resident needed assistance with hand washing and nail care.
A dependent resident with dementia and a history of stroke, identified on the MDS as requiring staff assistance for showers, did not consistently receive scheduled bathing, and one CNA falsely documented that bathing had been provided. CNA task reports showed missed or undocumented baths on scheduled days, and an internal investigation confirmed that a bath recorded as completed on one date had not actually occurred. Staff interviews indicated that if bathing was not documented it usually did not occur, and that scheduled bathing was expected to be provided by staff.
The facility failed to ensure dependent residents consistently received required assistance with ADLs, specifically bathing and toileting. One resident with muscle weakness and cognitive impairment, dependent on staff for showers, went a 10‑day period without any documented bathing, with CNAs acknowledging they marked tasks as not applicable when they lacked time or did not always offer showers. Another cognitively intact resident, dependent on staff for toileting and occasionally incontinent, reported waiting up to an hour for toileting assistance, and multiple CNAs confirmed observing incontinent episodes after prolonged waits and seeing the resident’s call light on while the resident waited to use the toilet. A third resident requiring substantial assistance with bathing, scheduled for twice‑weekly baths, received only four baths in a month and had a 10‑day gap without bathing, which later prompted a complaint; an agency CNA stated she did not recall refusals and sometimes could not complete the resident’s bathing.
A dependent hospice resident with cancer, mixed bladder incontinence, and a coccyx pressure injury was not provided incontinent care or repositioning for about seven hours, despite a care plan requiring checks, changes, and turning at least every two hours. A CNA assigned to the resident acknowledged she only visually checked the brief once, did not change it, and did not reposition the resident due to the resident’s pain, and later wrote a note asking others to keep an LPN from entering the room because care had not been done. Other CNAs and the charge RN reported it was apparent the resident had not been changed, and staff confirmed that standard practice was to provide incontinence care and repositioning per the care plan.
Two dependent residents did not receive scheduled showers needed to maintain hygiene and dignity. One resident with quadriplegia, aphasia, and severe cognitive impairment was care planned for staff-assisted showers but, over multiple scheduled opportunities, received only a few showers, some bed baths, and no documented make-up showers for several missed or refused shower days, despite family complaints of strong body odor and greasy hair and staff acknowledgment that showers were important. Another resident with diabetes, metabolic encephalopathy, and bowel and bladder incontinence, who preferred showers and was scheduled for twice-weekly bathing, had only one shower documented over about a month, with no evidence of additional offers when showers were missed. Staff interviews revealed that residents rarely refused showers, that agency CNAs frequently documented refusals without offering showers, and that heavy reliance on agency staff and workload issues, especially on evening and weekend shifts, led to showers not being completed as scheduled.
A resident dependent on staff for toileting, with a history of stroke and language deficits, was left alone on the commode despite a care plan and posted instructions requiring staff presence. The assigned CNA was unaware of the updated care plan due to an unupdated Kardex, resulting in the resident experiencing distress and filing grievances regarding unmet needs and delayed assistance.
A resident requiring maximum assistance and use of a Hoyer lift for bathing did not receive scheduled showers on multiple occasions due to lack of staff and equipment availability. Staff and a family member confirmed that bathing was not provided as care planned, and documentation reflected missed showers without make-up baths.
A resident dependent on staff for bathing, with diagnoses including COPD and metabolic encephalopathy, did not consistently receive scheduled showers as required by their care plan. Documentation showed missed showers on several scheduled days, with no evidence that additional opportunities were offered or refusals recorded. Staff interviews confirmed that blank logs indicated care was not provided, and one missed shower was attributed to short staffing.
A resident with severe cognitive impairment and a care plan requiring denture cleaning did not receive necessary oral care assistance from staff. Family members reported having to clean and insert the resident's dentures themselves, and staff interviews revealed inconsistent awareness and communication regarding the resident's denture care needs. Observations confirmed the resident wore dentures overnight and had mouth odor, indicating a lack of proper oral hygiene support.
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