Failure to Implement Therapy Recommendations for Safe Transfers
Summary
A deficiency was identified when a resident with multiple complex diagnoses, including sarcoid myocarditis, muscle weakness, and difficulty walking, experienced a fall during a transfer from a recliner to a wheelchair. The fall occurred when the resident's knees buckled, and the CNA assisted the resident to the floor and then to a wheelchair with a two-person stand and pivot. The root cause investigation determined that the fall was due to the resident's leg weakness, and the resident's fall risk assessment was updated from low to moderate following the incident. Despite recommendations from the physical therapist for staff to use a front-wheeled walker and a gait belt during transfers, interviews with CNAs revealed that these assistive devices were not being used. The resident confirmed that staff did not use a gait belt or walker when transferring, even though the physical therapist had recommended their use. The care plan and Kardex were updated to indicate a two-person assist for transfers after the fall, but did not specify the use of a gait belt or walker as recommended by therapy. The Director of Nursing confirmed that using a gait belt is considered standard of care and that staff are educated on therapy recommendations through a communication binder and updates to the Kardex system. However, the DON was not aware of the specific PT recommendation for the use of a walker during transfers for this resident. The facility's falls protocol requires staff to identify and implement pertinent interventions based on assessment, but the lack of adherence to therapy recommendations for assistive devices contributed to the deficiency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
A resident with intact cognition and multiple medical conditions, requiring moderate assistance with bathing, did not consistently receive showers according to her stated preference to bathe before 7:30 A.M. The shower schedule listed specific days on day shift but did not reflect this time preference, and electronic records showed only one shower documented for an entire month, despite the resident reporting that staff sometimes did not provide showers and then recorded them as refusals. Nursing notes showed refusals when showers were offered after the resident’s preferred time, and the DON confirmed gaps in shower documentation, contrary to facility policy requiring bathing according to resident preferences and proper documentation.
A resident with multiple chronic conditions who required assistance with personal care did not receive a requested shower before a scheduled medical appointment. Despite the facility's policy to provide showers as needed and upon request, staff did not document or provide the requested care, as confirmed by interviews with the resident, a CNA, and the DON.
A resident with intact cognition and on a blood thinner was not shaved according to his preferences, as staff avoided shaving him due to his medication, despite care plan instructions for caution and supervision. The resident expressed dissatisfaction, and observation confirmed he was unshaven, contrary to facility policy.
A resident with impaired cognition and mobility requested assistance to use the bathroom but was instructed by a CNA to urinate in her incontinence brief instead of being assisted to the toilet, despite a care plan that included a toileting program. The CNA did not follow the care plan interventions, resulting in the resident not being given the opportunity to maintain her ability to perform activities of daily living related to toileting.
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.
Failure to Honor Bathing Preferences and Document Showers
Penalty
Summary
The facility failed to ensure a resident’s bathing preferences were accommodated and that showers were consistently provided and documented. The resident, who had intact cognition and did not refuse care per the Quarterly MDS, required moderate assistance with bathing and had multiple medical diagnoses including volvulus, UTI, osteoarthritis, peripheral neuropathy, breast cancer, skin cancer, acute embolism of the right lower extremity, and osteoporosis. Nursing notes documented that the resident refused showers on two occasions when staff attempted to bathe her after 7:30 A.M., stating she would not take a shower after that time. The shower schedule indicated the resident was to receive showers on the day shift on Mondays and Thursdays, but it did not reflect her preference to bathe before 7:30 A.M. Review of the electronic charting system showed that in December only one shower/bath was documented for the resident, on 12/22, with no documentation of showers from 12/01 through 12/21. During an interview, the resident reported she had not received a shower the prior week and stated that staff were documenting refusals when she had not refused, explaining that on days with only two aides working, showers were not done. She also stated she preferred to shower first thing in the morning and sometimes staff did not get to her in time, resulting in her not receiving a shower. The DON acknowledged awareness of issues with shower documentation and confirmed that the resident had no showers documented prior to 12/22, while also stating that the resident frequently refused showers if they were not offered before 7:30 A.M. The facility’s policy required residents to be bathed according to their preferences to promote cleanliness and comfort and to observe skin condition, which was not followed in this case.
Failure to Provide Timely Assistance with Activities of Daily Living
Penalty
Summary
A deficiency occurred when a resident with multiple chronic conditions, including COPD, asthma, rheumatoid arthritis, muscle weakness, and a need for personal assistance with personal care, did not receive timely assistance with activities of daily living as required by their care plan. The resident was admitted with significant medical needs and required supervision or touching assistance for showers, dressing, footwear, and personal hygiene. Documentation showed the resident requested a shower before a scheduled medical appointment, but there was no record or progress note indicating that the shower was provided on the requested date. Interviews with the resident, a CNA, and the DON confirmed that the resident's request for a shower prior to the appointment was not fulfilled, and there was no documentation to support that the care was provided as per facility policy. The facility's policy required staff to offer and assist with bathing according to the resident's care plan, including extra showers upon request or before appointments. The failure to provide the requested assistance resulted in non-compliance with the facility's own standards and regulatory requirements.
Failure to Provide Shaving per Resident Preference While on Anticoagulant
Penalty
Summary
The facility failed to ensure that a resident was shaved according to his preferences, despite his ability to express his wishes and having intact cognition. The resident, who had multiple medical diagnoses including acute respiratory failure, heart failure, and chronic kidney disease, was admitted with an order for Plavix, a blood thinner, which placed him at risk for bleeding. The care plan specified that caution should be used when shaving and that staff should provide setup and supervision for personal hygiene, taking into account the resident's daily preferences and fluctuating abilities. During the resident's stay, there was no documented evidence that he was shaved, and interviews revealed that staff refrained from shaving him due to his anticoagulant therapy, stating that only a nurse could perform the task. The resident expressed feeling bad about not being shaved and indicated that his preference was not being met. Observation confirmed that his beard had grown to approximately a quarter inch. The facility's policy on shaving emphasized cleanliness and skin care safety, but this was not followed in the resident's case.
Failure to Provide Resident Opportunity for Toileting
Penalty
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.