Surveyors found that staff failed to provide and accurately document ADL assistance for multiple residents, including oral hygiene and scheduled showers. One resident’s oral care was marked as “not applicable” without any indication of refusal, and another resident had severe dental plaque despite a care plan requiring twice-daily teeth brushing. The DON acknowledged that staff were using “not applicable” instead of documenting refusals. A resident with Dementia and Parkinson’s Disease, who depended on staff for ADLs and preferred showers, was scheduled for twice-weekly showers but received only a few showers and bed baths over a month, with several missed showers recorded as “not applicable.”
Three residents did not receive scheduled showers or adequate assistance with ADLs as documented in their care plans, with staff and resident interviews confirming missed care and lack of refusals. The DON verified that documentation did not support that showers were provided as scheduled.
Several residents dependent on staff for ADL care experienced significant delays in receiving incontinence care and hygiene assistance, often waiting over an hour for help. Residents and observations indicated that call lights were frequently left unanswered, and staff shortages led to prolonged periods where residents remained soiled or unassisted, despite care plans documenting their need for substantial or maximal assistance.
The facility did not consistently provide dependent residents with required assistance for ADLs such as showers, oral care, and grooming. One resident with hemiplegia missed multiple scheduled oral care and bathing sessions, while another resident who preferred showers received only bed baths and was unable to access the shower room due to equipment and space limitations. A third resident, who is blind and requires extensive help, did not receive scheduled hygiene care on several occasions. These deficiencies were confirmed through documentation, resident interviews, and staff observations.
Surveyors found that several dependent residents did not consistently receive scheduled showers or bed baths, with significant gaps in care and missing documentation. Interviews with residents, family, and staff, as well as review of care plans, revealed that showers were missed due to staff changes and lack of follow-through, and that there was no written policy for bathing frequency. The DON confirmed that expected care and documentation were not consistently provided.
A resident who was totally dependent for feeding and personal hygiene did not consistently receive documented assistance with meals and missed multiple showers or bed baths over several days. The DON confirmed the lack of documented feeding assistance and hygiene care during the periods identified.
A resident who was dependent on staff for ADL care was not provided with scheduled showers or bed baths for seven consecutive days, despite being listed on the facility's shower schedule. The DON acknowledged that nurse aides did not follow the posted schedule, and a regional RN confirmed the lapse in care.
Three dependent residents did not consistently receive scheduled showers or bed baths, with some experiencing gaps of up to nine days without hygiene care. Residents reported that receiving showers depended on staffing levels, and nursing assistants confirmed difficulties in providing all scheduled care, especially in the evenings.
A resident with multiple chronic conditions and total dependence on staff for ADLs was found with long, jagged fingernails, despite a care plan requiring staff to provide all personal hygiene. Family and staff interviews, as well as direct observation, confirmed that nail care was not performed as needed.
Several dependent residents did not receive scheduled showers or bed baths, with some going extended periods without bathing and lacking proper documentation for missed care. Observations found residents in disheveled states with poor hygiene, and staff confirmed the failure to provide required ADL assistance.
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