Federal inspectors who visited the facility in late January documented basic hygiene failures affecting multiple residents. One person's toenails measured approximately an eighth of an inch long and appeared jagged on both feet. The same resident had a whitish-yellow substance caked on his front teeth.
Inspectors observed the resident on consecutive days. His condition remained unchanged — the jagged toenails, the caked substance on his teeth.
When questioned, the resident explained he had asked staff for nail care assistance. Nobody would help him. His family members had stepped in to brush his teeth because facility staff couldn't find time for oral hygiene.
A certified nursing assistant told inspectors that nail care should happen after residents shower. She blamed lack of staffing for the resident not receiving oral hygiene assistance.
The Licensed Practical Nurse explained that CNAs and nurses can trim residents' toenails unless the person has diabetes. In those cases, only a nurse or podiatrist should provide nail care. She expected nursing assistants to document on shower sheets when residents need nail trimming and to assist with oral hygiene.
The Director of Nursing said she expected residents to have clean, trimmed toenails and for staff to help with oral hygiene.
Another resident spent days confined to bed wearing only a green hospital gown. The person was cognitively intact and required substantial to maximum assistance moving from bed to chair due to heart disease, kidney disease, and high blood pressure.
Inspectors observed the resident in bed on his back during multiple visits over a five-day period. Each time, he wore the same green hospital gown.
"I would like to get out of bed and wear clothing," the resident told inspectors. He was reluctant to ask staff to place him in a chair because they would leave him there too long. He mentioned having a special chair but didn't know where it was.
The next day, inspectors found him still in bed wearing the hospital gown. He hadn't gotten out of bed that day and believed he was "too much work" for staff since he required a Hoyer lift to transfer. The resident said he would like to see things outside his four walls.
The Director of Therapy confirmed the resident had no medical restrictions preventing him from getting out of bed. Staff were supposed to use a Hoyer lift for transfers. A special high-back wheelchair had been ordered and was already in the resident's room.
A nursing assistant claimed the resident was offered opportunities to get out of bed but would refuse. She acknowledged he required the mechanical lift for transfers.
The Director of Nursing said residents were expected to get out of bed daily and upon request. If someone refused care, nurses should be notified. She expected refusals to be documented in medical records and care plans.
Yet facility records showed no completed care plan for this resident despite his substantial care needs.
The resident's medical record contained no care plan addressing his activities of daily living requirements. His quarterly assessment showed he needed substantial to maximum assistance with basic movements like rolling in bed and transferring to chairs.
Both residents' situations revealed a pattern of unmet basic care needs. One person's family had to provide oral hygiene that staff should deliver. Another remained isolated in bed, dressed only in a hospital gown, while his specialized wheelchair sat unused in his room.
The facility's own policies required the care these residents weren't receiving. Staff acknowledged their responsibilities but cited staffing shortages and workload pressures as barriers to providing basic assistance with hygiene and mobility.
Federal inspectors classified the violations as having minimal harm or potential for actual harm to some residents. The findings emerged from a complaint investigation completed January 29.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grove At Kirkwood, The from 2026-01-29 including all violations, facility responses, and corrective action plans.