Failure to Provide Communication Board for Non-English Speaking Resident
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident with a communication barrier due to language. The resident, admitted with chronic respiratory failure, was assessed as having no memory problems and communicated only in Russian. The care plan specified the use of a communication board to facilitate communication between staff and the resident. However, during multiple observations and interviews, it was found that the communication board was not available in the resident's room, and staff were unable to effectively communicate with the resident without it. Staff, including a licensed nurse and a social worker, confirmed the absence of the communication board and acknowledged the difficulty in communicating with the resident as a result. The Director of Nursing also confirmed that the care plan required the use of a communication board and emphasized its importance for providing appropriate care. A review of facility policy indicated that communication boards should be provided for non-bilingual staff to communicate with residents who have language barriers, but this was not implemented for the resident in question.
Plan Of Correction
The DSD or designee (in conjunction with Social Services) will conduct daily audits of residents requiring communication boards for 2 weeks, then weekly for 1 month, and monthly thereafter to ensure devices are present and properly utilized. The Social Services Director will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee quarterly for 2 quarters or until substantial compliance is achieved and maintained. The QAPI committee will make recommendations for additional interventions or modifications as needed. All corrective action will be completed by 5/26/25.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to provide and/or document scheduled biweekly showers for two residents who required staff assistance with ADLs, including bathing, per their MDS assessments and care plans. Both residents had multiple chronic conditions such as muscle weakness, COPD, dementia, obesity, diabetes, and bipolar disorder, and were care planned to receive staff assistance with bathing according to their preferences. Review of shower records showed multiple missed or undocumented showers on scheduled days, and both residents reported not receiving showers as scheduled, with one expressing upset about the missed care. The DON confirmed there was no documentation that the scheduled showers occurred, despite a facility ADL policy requiring necessary services to maintain grooming and personal hygiene.
Surveyors found that the facility failed to provide adequate ADL support and honor bathing preferences for two residents who were cognitively intact and required staff assistance with bathing. One resident, who preferred morning baths and was care planned to be kept clean, dry, and odor free, received only a few baths during a month, with no documented refusals and an instance where she only received a sponge bath late in the evening after repeatedly asking for a bath. Another resident, who preferred bed baths and refused showers, had an ADL care plan that was not revised to reflect specific bathing preferences or frequency, and documentation showed inconsistent bathing intervals and at least one shower given despite the stated preference. Staff interviews confirmed that care plans did not accurately reflect these residents’ bathing preferences or needed frequency of care.
A resident with intact cognition and multiple chronic conditions, including OA, CHF, COPD, and impaired vision, was ordered to receive showers twice weekly and required supervision/touching assistance. Shower documentation showed missed scheduled baths/showers and only partial completion of the ordered routine, with the resident stating she was not receiving showers as scheduled. The DON confirmed only three showers were documented for one month and no additional records supported the missing care.
A resident with severely impaired cognition and limited English proficiency was unable to effectively communicate needs because staff did not consistently use a communication board or other reliable translation support. The resident could understand only simple English words, had oral problems that affected speech and translation accuracy, and reported difficulty telling staff about pain, poor intake, mouth discomfort, and a request for dental care. Staff and a roommate confirmed no communication board was in the room and that translation support was not routinely used.
A resident with moderate cognitive impairment and multiple serious cardiac, vascular, and renal conditions was assessed and care planned to use bilateral half enabler bars/side rails for weakness and to assist with bed mobility and ADLs. Physician orders also specified bilateral assist bars/side rails for bed mobility. However, the bed in the resident’s room did not have any side rails or enabler bars in place, and an LPN confirmed the resident never had enabler bars on the bed. The Maintenance Director reported he never received a work order to install enabler bars after the resident transferred from the skilled unit to the LTC unit and therefore did not apply them, despite facility policy requiring assessed side rail use for mobility to be addressed in the plan of care and implemented.
Surveyors found that two residents who required staff assistance with ADLs and personal grooming did not receive timely facial hair removal despite care plan directives and facility policy. One resident with multiple chronic conditions and intact cognition was observed in a common area with long, noticeable chin hairs after stating that staff usually shaved them but had not done so that day, a fact confirmed by an LPN. Another resident with moderate cognitive impairment and multiple medical diagnoses was observed with prominent upper and lower lip hair resembling a mustache, reported that it was bothersome, and had a blank shower documentation sheet despite requiring assistance with showering and shaving. An LPN stated that CNAs are expected to shave female residents when facial hair is noticeable, even on non-shower days, but acknowledged that both residents’ requests for shaving had not been carried out, contrary to facility ADL and hygiene policies.
Failure to Provide and Document Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure residents received scheduled showers necessary to maintain activities of daily living (ADLs), resulting in missed showers for two residents who required staff assistance. One resident, admitted with diagnoses including muscle weakness, anxiety, dysarthria and anarthria, severe protein-calorie malnutrition, COPD, tobacco use, and dementia, had an MDS showing a need for partial to moderate assistance with showering and bathing. The resident’s care plan, revised in early February, identified a need for staff assistance with ADLs, including bathing as needed and per preference, and the shower schedule indicated biweekly showers on Wednesdays and Saturdays. Review of shower documentation showed no record of showers on two scheduled dates, and the resident reported not receiving scheduled showers on a regular basis. The DON confirmed there was no documentation that the resident received showers on those dates. Another resident, admitted with muscle weakness, osteoarthritis, polyneuropathy, obesity, bipolar disorder, hypertension, heart failure, COPD, BMI greater than 50 percent, and diabetes mellitus, had an MDS indicating a need for substantial to maximal assistance with showering and bathing. The care plan, updated in early April, documented the need for staff assistance with ADLs related to multiple chronic conditions, with interventions to assist with bathing as needed and per resident preference, and the resident was also scheduled for biweekly showers on Wednesdays and Saturdays. Shower documentation lacked entries for multiple scheduled shower dates, and the resident stated they had missed showers over the previous two weeks and were upset when this occurred. The DON confirmed there was no documentation that the resident received showers on the identified dates. Facility policy on ADLs required that residents unable to carry out ADLs receive necessary services to maintain grooming, personal hygiene, oral hygiene, and good nutrition.
Failure to Provide ADL Support and Honor Resident Bathing Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to support residents’ activities of daily living (ADLs), specifically bathing, in accordance with assessed needs and stated preferences. One resident with a BIMS score of 15, indicating no cognitive impairment, required assistance with multiple ADLs including bathing and toileting and was care planned to be kept clean, dry, and odor free, with staff assistance for hair care, toileting, and bathing as needed per preference. Shower/bed bath records for this resident in February 2026 showed only three baths provided during the month, with one missed due to lack of hot water and no documentation of refusals for the remainder of the month. The resident reported preferring morning baths and stated that on one day she repeatedly asked staff when she would be bathed, did not receive a bath during the day, and ultimately received only a sponge bath while on the toilet in the evening, leaving her feeling that her preferences and opinions did not matter. The Corporate Clinical Director confirmed the resident was not being bathed or showered per her preference or needed frequency. A second resident, who was cognitively intact and required moderate assistance with bathing, had an ADL care plan indicating a need for staff assistance with bathing per preference, but this care plan was not revised to reflect the resident’s specific bathing preferences or frequency. Another care plan addressing inappropriate behavior documented that this resident preferred bed baths and refused showers. Electronic ADL records for February and March 2026 showed that baths/showers were provided on several specific dates, with one documented refusal and at least one shower given despite the resident’s stated preference for bed baths. Interview with an RN confirmed that the ADL care plan was not updated to include the resident’s bathing preferences, including frequency, and that there were often five days between documented bathing. These findings, based on record review, staff and resident interviews, and documentation audits, demonstrate that the facility did not consistently provide ADL care, particularly bathing, in alignment with residents’ assessed needs and expressed preferences.
Failure to Provide Ordered Bathing and Maintain ADLs
Penalty
Summary
The facility failed to ensure a resident received bathing as ordered and to maintain ADLs. Resident #1 was admitted with diagnoses including bilateral primary osteoarthritis of the knee, chronic diastolic CHF, COPD, and bilateral nonexudative age-related macular degeneration. The resident’s MDS showed intact cognition and that she required supervision or touching assistance with showering/bathing. The physician ordered baths/showers two times per week, on Wednesday and Saturday, and the ADL care plan identified the resident as having potential functional status deficits related to deconditioning, weakness, pain, impaired vision, hearing difficulty, and chronic pain, with staff support and supervision/touching assistance for showers/baths. Review of shower sheets from January and February 2026 showed the resident received only some of the ordered showers and missed multiple scheduled shower days. The record documented refusals on two occasions, but the shower sheets did not show that the resident refused personal hygiene on the days she accepted a shower, and there was no documentation supporting that she received showers on several ordered dates. The resident stated she was not receiving showers twice a week per schedule. The DON confirmed the resident received only three baths/showers in February 2026 and that there were no additional documents to support further showers. The facility policy stated residents are to be assisted to the extent necessary for completion of ADLs on a daily basis and as needed.
Limited English Communication Support Not Provided
Penalty
Summary
The facility failed to develop an effective means of communication for a resident who spoke limited English, affecting the resident’s ability to communicate requests and needs. Resident #89 was admitted with diagnoses including age-related osteoporosis with pathological fracture, adult failure to thrive, protein calorie malnutrition, major depressive disorder, unspecified dementia, systolic heart failure, and alcohol abuse. The MDS assessment showed severely impaired cognition and maximum assistance and cuing were required for all ADLs. During observation and interview, the resident had difficulty communicating because he spoke only Spanish, could understand only some simple English words, and was unable to respond effectively to questions about care or treatment. No communication board was present in the room for needs such as pain, bathroom, food, water, or hygiene. Interviews confirmed that staff were not consistently using communication tools with the resident. A roommate stated staff did not use a communication board or electronic translator when providing care and did not ensure the resident understood directions. The resident later reported difficulty communicating with staff, poor intake, weight loss related to dental problems, dislike of the pureed diet, mouth pain while eating, and a request for dental care and improved oral care and diet. Speech therapy confirmed the resident understood only very simple words and commands in English, could not carry on a conversation, and had oral problems that affected speech and translation accuracy. Nursing staff and CNA staff confirmed no communication board or posted translated words were present in the room, and the intake/admission director stated she was often called to translate but was not always available onsite; she also confirmed communication boards had not been used with the resident.
Failure to Implement Ordered Enabler Bars for Bed Mobility
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered enabler bars/side rails for a resident to assist with bed mobility as assessed and care planned by the facility. The resident was admitted with multiple serious diagnoses, including cellulitis with gangrene of both great toes, peripheral vascular disease, bacteremia, significant coronary artery disease, heart failure with preserved ejection fraction, end stage renal disease requiring hemodialysis, chronic combined systolic and diastolic CHF, angina, and multiple coronary stent placements. An admission MDS showed moderate cognitive impairment. An enabler assessment documented an order for half enabler bars on both sides of the bed for weakness, with stated benefits including aiding in maintenance of proper body alignment, posture for eating and breathing, appearance, and assistance with ADLs. The resident’s care plan included bilateral enabler bars for bed mobility, and physician orders for January documented bilateral assist bars/side rails to aid in bed mobility. Despite these assessments, care plan entries, and physician orders, the enabler bars were not implemented on the resident’s bed. Observation of the former room after the resident’s discharge showed the bed had no side rails or enabler bars in place. An LPN reported that the resident did not have enabler bars on the bed while residing at the facility. The Maintenance Director stated he had not received a work order to apply enabler bars after the resident transferred from the skilled unit to the LTC unit and confirmed he did not apply them. A RN confirmed the transfer date from the skilled unit to the LTC unit. The facility’s policy on proper use of side rails stated that side rails may be used to assist in mobility and transfer, that an assessment would determine the reason for use, and that use of side rails as an assist device would be addressed in the plan of care, which had been done for this resident but not carried out in practice.
Failure to Provide Timely Facial Hair Grooming for Dependent Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide timely hygiene care, specifically shaving and removal of facial hair, for residents who required assistance with activities of daily living (ADLs). One resident with Parkinson’s disease, right shoulder pain, impaired mobility, COPD, bipolar disorder, obesity, osteoarthritis, heart failure, seizures, and other conditions was cognitively intact and required touching assistance for personal grooming, including shaving, per the MDS and care plan. The care plan documented an actual risk for ADL decline and the need for staff assistance with hygiene. During observation, this resident was seen in a common area with multiple long, white chin hairs that were noticeable. The resident reported being unable to find tweezers and stated that staff usually shaved the chin whiskers but had not done so that day. An LPN confirmed the presence of multiple long white chin hairs and that the resident had requested their removal, which had not been done. Another resident with atrial fibrillation, hypertension, osteoarthritis, anxiety disorder, hypothyroidism, major depressive disorder, ischemic heart disease, anemia, and electrolyte imbalance had moderate cognitive impairment and required moderate assistance for showering and personal hygiene, including shaving, as documented on the MDS and care plan. The care plan indicated an ADL self-care performance deficit related to impaired mobility and required staff assistance for showering and personal hygiene, including shaving. Review of a shower sheet for this resident showed a blank space where shower documentation should have been. Observation revealed multiple black hairs on the resident’s upper and lower lips with the appearance of a mustache, and the resident stated the facial hair bothered her because it did not look good. An LPN stated that female residents’ facial hair is to be shaved on shower days and when noticeable, and that CNAs are expected to shave female residents with facial hair even if it is not their shower day. The LPN confirmed the facial hair on this resident and that the resident had asked for it to be shaved but it remained. Facility policy required that residents unable to carry out ADLs independently receive services necessary to maintain grooming and personal hygiene, including support and assistance with hygiene in accordance with the plan of care.
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