Federal inspectors documented the hygiene neglect during a September complaint investigation, finding the resident unshaved with food debris and dry skin accumulating in his facial hair across multiple days of observation.
The resident, identified as Resident K in inspection records, had diagnoses including dementia and acute osteomyelitis. His care plan, last updated August 21, specifically required staff assistance with grooming and hygiene needs.
On September 2 at 10:55 a.m., inspectors observed the resident lying in bed with "a heavy growth of beard on his face with dry flakey skin in his beard." The next day, he remained unshaved with "dry, flakey skin in his beard and food on his face."
By September 4, inspectors found him still unshaved with "dry skin and food stuck in his beard and on the corners of his mouth." When asked about shaving, the resident told inspectors "he used to get shaved."
The deterioration continued. On September 5, inspectors observed him sitting in his wheelchair wearing a black t-shirt, still unshaved with "dry skin in his beard" and "dried skin flakes present by the collar of his shirt, under his chin." His mouth corners had turned red from the neglect.
Licensed Practical Nurse 14 acknowledged the obvious hygiene problems during an interview that day, telling inspectors there was "dried skin in Resident K's beard and probably flakes of potato chips that he liked to eat."
The facility's care plan outlined specific interventions for the resident's daily living needs, including "assisting with bathing as needed, assisting with dressing, grooming and hygiene as needed." Staff were supposed to encourage him to do as much for himself as possible while providing necessary assistance.
Certified Nurse Aide 16 told inspectors she sometimes cared for the resident and that he required "extensive assistance" with daily activities. While she said he would sometimes refuse care, "she had not known him to refuse to wash his face or shave." She noted that residents were typically shaved on their designated shower days.
Registered Nurse 18 confirmed the resident's shower schedule was Wednesday and Saturday evenings. Yet across the four-day inspection period, no staff member washed his face or provided basic grooming care.
The resident's care plan noted additional challenges related to his vascular dementia diagnosis. He had "impaired daily decision-making skills and poor insight into care" and would sometimes "refuse medications or allow staff to get him out of bed." Staff documented that he would "refuse showers at times" and "continuously" used his call light claiming his television was malfunctioning.
The plan also revealed family insights about his personality, noting he had "always been very cautious of taking medications and believed that taking vitamins was the way to maintain good health." Licensed Practical Nurse 14 told inspectors the resident "was picky about things" and had "previously lived off the grid."
Despite these documented behavioral challenges, the care plan made no accommodation for his apparent refusal of basic hygiene care. The facility's interventions focused on medication compliance and repositioning difficulties but failed to address the fundamental grooming needs that inspectors witnessed deteriorating over multiple days.
Only when the Director of Nursing Services intervened during the inspection on September 5 at 2:24 p.m. did anyone address the resident's condition. Inspectors watched as the nursing director "obtained a warm washcloth and gently washed Resident K's face."
The timing of this intervention, occurring only after days of documented neglect and during active federal scrutiny, highlighted the facility's failure to maintain basic hygiene standards for vulnerable residents.
Federal regulations require nursing homes to provide care and assistance for residents unable to perform activities of daily living independently. The inspection found Harrison Terrace failed this fundamental obligation, leaving a dementia patient with food debris and skin irritation while staff acknowledged the problems but took no corrective action.
The citation stemmed from a complaint investigation, suggesting someone outside the facility noticed and reported the inadequate care conditions. The resident's deteriorating appearance over four consecutive days demonstrated a systemic failure rather than an isolated incident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harrison Terrace from 2025-09-08 including all violations, facility responses, and corrective action plans.