GARBERVILLE, CA - A certified nursing assistant at Jerold Phelps Community Hospital Skilled Nursing Facility performed unauthorized grooming on a vulnerable resident with severe cognitive impairment, according to a federal inspection report released following an April 2025 investigation.
Unauthorized Personal Care Incident
The incident involved a resident with severe cognitive impairment, dementia, Parkinson's disease, anxiety, and depression who required staff assistance with all toileting hygiene. According to the inspection report, a CNA shaved the resident's pubic hair on March 29, 2025, without obtaining consent, medical orders, or following proper care planning procedures.
A colleague who witnessed the incident reported that the CNA used the resident's personal beard shaver to perform the grooming. The witness stated she was confused about why the grooming occurred since "Resident 1 had not asked for it and CNA A had not given a reason why she did it." The witness noted the resident appeared agitated during the procedure but did not ask the CNA to stop.
The unauthorized grooming left the resident's pubic area "shaved sloppily" with hair remaining on the sides and redness on the skin, according to nursing staff observations documented in the report.
Attempt to Conceal Incident
Several days after the March 29 incident, the CNA who performed the grooming called her colleague who had witnessed it, asking her "not to tell anybody she had shaved Resident 1's pubic area." This request occurred on April 3, the same day another nurse observed and reported the resident's condition.
The colleague who witnessed the original incident reported what she had seen to nursing supervision on April 5, which initiated the facility's investigation process.
Medical and Care Standards Violations
Personal grooming procedures in nursing facilities must follow established care plans and obtain appropriate authorization. For residents with cognitive impairment, particular protocols exist to ensure dignity and prevent unnecessary distress.
The resident's documented conditions created additional vulnerabilities. Severe cognitive impairment, with a Brief Interview for Mental Status score of 5, indicated significant deficits in memory, orientation, and judgment. Combined with dementia and Parkinson's disease, these conditions would have made the resident unable to provide informed consent for the grooming procedure.
Parkinson's disease can cause muscle rigidity and movement difficulties, making any unnecessary physical manipulation potentially uncomfortable or distressing. The witnessed agitation during the procedure suggests the resident experienced distress from the unauthorized care.
Reporting Requirement Failures
The inspection revealed significant failures in the facility's abuse reporting procedures. Staff members who witnessed or became aware of the incident on March 29 did not report it to the California Department of Public Health within the required two-hour timeframe for suspected abuse allegations.
The Director of Nursing acknowledged that both the CNA who witnessed the incident and the licensed nurse who received the report were mandated reporters who "should have reported the allegation as soon as they were aware but no later than 2 hours of becoming aware of the suspicion of abuse on 3/29/25."
The facility did not submit the required initial report until April 7, more than a week after the incident occurred. Additionally, the facility failed to provide the mandatory 5-day follow-up investigation summary to state authorities.
Policy Deficiencies
Inspection of the facility's abuse and neglect policies revealed they did not include the required reporting timeframes. The facility's policies titled "Abuse and Neglect Investigation" and "Abuse Reporting Requirements" contained no documentation indicating the facility was required to report allegations of resident abuse within two hours of becoming aware of suspected incidents.
The Director of Nursing stated she learned about the two-hour reporting requirement from the facility's Chief Quality Officer during the investigation, indicating gaps in management understanding of mandatory reporting procedures.
Regulatory Standards for Personal Care
Federal regulations require nursing facilities to develop comprehensive care plans that address residents' personal care needs while maintaining dignity and preventing unnecessary distress. Any changes to personal care routines must be documented and justified by medical necessity or resident preference.
For residents with cognitive impairment, facilities must implement additional safeguards to prevent exploitation or inappropriate care. This includes ensuring that staff understand the resident's capacity for decision-making and obtaining appropriate consent when possible.
Personal grooming that goes beyond routine hygiene typically requires specific medical orders or inclusion in the resident's care plan. The lack of documentation or justification for the grooming procedure violated these established standards.
Investigation Outcomes
The facility placed the CNA who performed the unauthorized grooming on administrative leave pending completion of their investigation. The incident was reported to state authorities as suspected dependent adult abuse.
The inspection resulted in citations for violations of federal regulations regarding reporting requirements for suspected abuse and neglect. The facility received a "minimal harm or potential for actual harm" rating affecting few residents.
Facility Response Requirements
Nursing facilities must maintain comprehensive policies that clearly outline reporting requirements for suspected abuse or neglect incidents. Staff training must ensure all employees understand their obligations as mandated reporters and the specific timeframes for reporting to state authorities.
Facilities are also required to conduct thorough investigations of suspected incidents and submit detailed follow-up reports within specified timeframes. These requirements exist to protect vulnerable residents and ensure appropriate oversight of care quality.
The incident highlights the importance of proper supervision and training for nursing assistants who provide direct personal care to cognitively impaired residents. Clear protocols and ongoing education help prevent inappropriate care decisions and ensure resident dignity and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Jerold Phelps Comm Hosp Snf from 2025-04-17 including all violations, facility responses, and corrective action plans.
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